Contents

La Revue de Santé dela Méditerranée orientale

Eastern MediterraneanHealth Journal

Vol. 22 No. 11 • 2016 •املجلد الثاين و العرشون عدد 11

Editorial Vaccine preventable diseases and immunization during humanitarian emergencies: challenges and lessons learned from the Eastern Mediterranean Region N. Teleb and R . Hajjeh .............................................................................................................................................................................................................................................................................. 775

Research articles Trends in infectious disease incidence among children in Afghanistan at a time of public health services expansionM.Y. Anwar and G. Burnham ................................................................................................................................................................................................................................................................ 778Self-reported versus proxy reported quality of life for breast cancer patients in the Islamic Republic of IranF. Najafi, 1 S. Nedjat, 1,2 K. Zendehdel, M. Mirzania and A. Montazeri .................................................................................................................................................................................. 786Messaging standard requirements for electronic health records in Islamic Republic of Iran: a Delphi studyM. Ahmadi, S. Foozonkhah, L. Shahmoradi and A.D. Mahmodabadi ................................................................................................................................................................................... 794Oral health status, knowledge and practice among pregnant women attending Omdurman maternity hospital, SudanH.M. El-Mahdi Ibrahim, A.M. Mudawi and I.A. Ghandour ..................................................................................................................................................................................................... 802Factors affecting breastfeeding practices among working women in PakistanJ.A. Soomro, Z.N. Shaikh, S.A. Bijarani and T.B. Saheer ............................................................................................................................................................................................................. 810Psychobehavioural responses to the 2014 Middle East respiratory syndrome-novel corona virus (MERS CoV) among adults in two shopping malls in Jeddah, western Saudi ArabiaN.S. AlNajjar, L.M. Attar, F.M. Farahat and A. AlThaqafi ......................................................................................................................................................................................................... 817Association between attitudes towards Internet usage and health practices in high-school students in 2 schools in Turkey: a cross-sectional studyN. Kaya, T. Aşti, İ. Kaya, S. Yaylaci, K. Kaya, N. Turan and G. Özdemir Aydin .................................................................................................................................................................. 824

Short communication Implementation of a mentored professional development programme in laboratory leadership and management in the Middle East and North AfricaL.A. Perrone, D. Confer, E. Scott, L. Livingston, C. Bradburn, A. McGee, T. Furtwangler, A. Downer, A.H. Mokdad, J.F. Flandin, S. Shotorbani, H. Asghar, H.E. Tolbah, H.J. Ahmed, A. Alwan and R . Martin ................................................................................................................................................................................................. 832

ReportStrengthening national health information systems: challenges and responseA. Alwan, M. Ali, E. Aly, A. Badr, H. Doctor, A. Mandil, A. Rashidian and O. Shideed ..................................................................................................................................................... 840

WHO events addressing public health prioritiesDeveloping capacity-building of general practitioners in the Eastern Mediterranean Region ..................................................................................................... 851

Ala Alwan, Editor-in-chief

Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk

International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf

Editors Phillip Dingwall Guy Penet (French) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Freelance) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics)

Graphics Suhaib Al Asbahi, Diana Tawadros

Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy

Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean Cover photograph ©World Health Organization

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1Regional Advisor, Vaccine Preventable Disease and Immunization (VPI), Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Director, Division of Communicable Disease Control (DCD), Regional Office for the Eastern Mediterranean, Cairo, Egypt

Editorial

Vaccine preventable diseases and immunization during humanitarian emergencies: challenges and lessons learned from the Eastern Mediterranean Region N. Teleb 1 and R. Hajjeh 2

The last few years have seen the WHO Eastern Mediterranean Region suffer from multiple wars and conflicts lead-ing to humanitarian emergencies of unprecedented magnitude. In addition to the many lives lost and affected, the conflicts have significantly impacted the infrastructure needed for delivery of healthcare services (1). Approximately 30 million people have fled their coun-tries; the refugee population in Jordan has doubled and even tripled in Leba-non (2). The population displacement and resettlement, overcrowding, pov-erty, poor sanitation, and malnutrition due to food shortages have increased morbidity and mortality from various diseases, notably communicable dis-eases.

Control of vaccine-preventable dis-eases (VPDs) is especially vulnerable to disruption of health-care systems due to the need for continuous imple-mentation and monitoring (3). The Syrian Arab Republic had a very strong immunization program prior to its cur-rent conflict, with more than 90 percent of children routinely vaccinated and the last polio case reported in 1999. However, diphtheria-tetanus-pertussis (DTP3) coverage in the country dropped to 41% in 2015; in 2013, less than two years after the start of conflict, the country experienced a polio out-break that paralyzed 35 children. To contain it, more than 25 million doses of oral polio vaccine were administered. In

2014, other VPDs resurged in the Syr-ian Arab Republic, including measles and pertussis. Both Jordan and Lebanon faced large outbreaks of measles due to the influx of Syrian refugees. In Lebanon alone, the measles incidence increased from 2.1to 411cases/million popula-tion in 2012 and 2013 respectively (3).

The Region has earlier demonstrated significant progress in measles control, with reported measles cases decreasing from 89,478 in 1998 to 10,072 in 2010 (77%) (4). However, with the political turmoil and significant decrease in do-nor funding, regional progress slowed and measles cases doubled to reach 20 898 cases in 2015. The regional average of DTP3 coverage gradually declined from 86% in 2010 to 80% in 2015 (WHO/UNICEF estimates). In 2015, 3.8 million infants missed their third DTP dose in the Region – more than 90% of these infants are in conflict-affected countries (EMRO, unpub-lished data).

Immunization activities during conflictRemarkable efforts were devoted to maintaining immunization programs and reaching every child with life-saving vaccines, even under active war and life-threatening situations. During 2011–2016, more than 248 million children aged 6 months to15 years were reached by measles-containing vaccines in conflict-affected countries

as well as countries hosting refugees in the Region (5).

While concerted partners’ support was a key factor for accessing required resources, governments’ commitment and allocation of national resources was critical. Most importantly, the devotion of health workers and their relentless efforts to reach children in hard to reach areas, and the demand from communi-ties for vaccines, were major success elements. The examples of Yemen and the Syrian Arab Republic best illustrate how concerted efforts at multiple levels are critical to sustain immunization cov-erage and prevent outbreaks of VPDs.

Yemen More than two million people in Yemen were displaced due to conflict and many health facilities destroyed (one third of health facilities and one fourth of vaccine stores). However, pentavalent vaccine (DTP-HepB-Hib) coverage dropped only slightly from 87% in 2010 to 84% in 2015 (6). To maintain cover-age, outreach activities were conducted in the remote areas (24,000 and 30,000 sessions in 2014 and 2015 respectively), in addition to three rounds of polio national immunization days (NIDs) each year, thus sustaining the polio-free status. Yemen also smoothly introduced two new vaccines (measles–rubella [MR] and inactivated polio vaccine [IPV]), while sustaining other new vaccines (Hib, rotavirus and pneumo-coccal vaccines). These achievements

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were possible through concerted ef-forts spearheaded by WHO, effective coordination among partners through weekly meetings attended by all key stakeholders, active utilization of the Health Cluster forum to advocate for immunization, establishing a functional immunization Operational Control Room at central and governorate levels, and the devotion of front-line immu-nization workers. The effective uses of resources, especially Global Alliance for Vaccines and Immunization (GAVI) support, and distribution of roles and re-sponsibilities among different partners, were instrumental.

Syrian Arab Republic When the conflict in the Syrian Arab Republic began in 2012, routine im-munization stopped in areas outside recognized government control. Dur-ing the short break in the conflict in February 2016, WHO and UNICEF in collaboration with the Syrian Ministry of Health and other supporting partners (Syria Arab Red Crescent, Syria Im-munization Group, and local NGOs), as part of Accelerated Implementation of Routine Immunization initiative (AIRI), conducted multiple antigens vaccination campaigns in the hard-to-reach areas deprived of access to routine vaccines. Every child born since the start of the conflict was provided with three doses of pentavalent vaccine, 3 doses of oral polio vaccine, 2 doses of MR vaccine, and one dose of IPV. Despite the active war in the north of the Syrian Arab Republic, three campaigns were implemented – 1.9 million doses of pentavalent vaccine, more than 1.3 mil-lion doses of MR vaccine, more than 1.9 million of OPV and 168,405 doses of IPV (EMRO, unpublished data).

The constant support of the part-ners, led by WHO and UNICEF, and the high dedication of the local NGOs and health workers were behind the exceptional success in the areas that im-plemented the campaigns. Independent post-campaign monitoring, using card

information or finger marking, proved that more than 90% of the children were reached — an incredible success in view of all the challenges.

ChallengesMultiple challenges were faced while supporting immunization activities in the Region during conflict. Many health facilities were destroyed and the func-tioning facilities faced major challenges with availability of fuel and electricity. Security concerns were major obstacles, affecting all planned activities, particu-larly outreach and mobile activities, and significantly increasing operational costs. Obviously, the active war in many areas made parents reluctant to take their children to health centres for vaccination. The resulting inadequate number of immunization staff who had fled conflict areas or were reassigned to other healthcare priority functions, was also a major difficulty. Lastly, in many countries, immunization activities were limited by the shortage of funds required for vaccine purchase and op-erational costs.

Policy levelThe Strategic Advisory Group of Ex-perts (SAGE) and the World Health Assembly requested in 2011 that WHO develops guidance on the delivery of immunization services in humanitar-ian emergency settings. In 2013, the final version of the framework entitled “Vaccination in acute humanitarian emergencies: a framework for decision making”, was released and dissemi-nated (7). The document provides key decision-makers in countries and partner agencies with a systematic and comprehensive approach to decision-making on the use of vaccines in acute humanitarian emergencies, taking into account various factors including the epidemiologic risk assessment, vaccine characteristics, and contextual factors. In addition, it provides guidance on ethical concerns such as prioritization of interventions, equity, and informed

consent. It is currently being updated to facilitate its use, based on input from various countries affected by conflict. In addition, a package of tools on vac-cination in humanitarian emergencies is being prepared, in order to provide practical guidance for delivering vac-cines and improving vaccination cover-age during these situations, as well as overcoming barriers to timely supply affordable vaccines.

Conclusions

Sustaining immunization activities and preventing VPD outbreaks during conflicts is very difficult and requires massive and adequately coordinated efforts by all parties involved, including governments and other political par-ties, since the health of populations and children should transcend all political considerations. Although emergencies often lead to disruption of immuniza-tions and other health services, their impact can be minimized if strong health systems are in place and ap-propriate preparedness measures are taken preemptively. Partners, whether technical, implementing or financial, play an even more important role in supporting public health programmes overall and immunization in particular during conflicts. Community engage-ment and demand for vaccines remains essential. Policy frameworks recently developed should serve as guidance for decision-making and implementation. The global community should recog-nize that the deterioration in the public health situation in the Eastern Mediter-ranean Region is of an unprecedented and dramatic scale. Communicable diseases, and VPDs in particular, require urgent attention. If adequate support, both financially and programmatically, is not consistently provided, the situa-tion poses an immense threat to health security globally, and to the success of major health initiatives such as polio eradication and measles elimination.

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References

1. Alwan, A. The cost of war. Newsweek Middle East edition, 5 November 2015 (http://newsweekme.com/the-cost-of-war/, accessed 23 January 2017).

2. Displaced populations. Geneva: World Health Organization; 2016 (http://www.emro.who.int/eha/displaced-popula-tions/index.html, accessed 26 January 2017).

3. Lam E, McCarthy A, Brennan M. Vaccine-preventable dis-eases in humanitarian emergencies among refugee and in-ternally-displaced populations. Hum Vaccin Immunother. 2015;11:2627-36.

4. Teleb N, Lebo E, Ahmed H, Hossam AR, El Sayed, Dabbagh A et al. Progress towards measles elimination – Eastern Mediter-ranean Region, 2008-2012. MMWR 2014;63:511-15.

5. Summary of supplementary immunization activities from January 2000 to December 2017. Geneva: World Health Organization; 2017 (http://www.who.int/entity/immuniza-tion/monitoring_surveillance/data/Summary_Measles_SIA_Jan2000_Dec2017.xls?ua=1, accessed 23 January 2017).

6. WHO/UNICEF Joint Reporting form 2015. Geneva: World Health Organization; 2016 (http://www.who.int/immuniza-tion/monitoring_surveillance/data/yem.pdf).

7. Vaccination in acute humanitarian emergencies: a framework for decision making. Geneva: World Health Organization; 2013 (http://www.who.int/hac/techguidance/tools/vac-cines_in_humanitarian_emergency_2013.pdf?ua=1, accessed 26 January 2017).

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1Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America (Correspondence to: M.Y. Anwar: manwar6@jhu.edu).

Received: 28/08/15; accepted: 03/07/16

ABSTRACT This study reviewed trends in the incidence of common communicable diseases among children under five years in Afghanistan between 2005 and 2013, a period of expansion of public health services. New visits to outpatient clinics constituted the denominator for calculating proportions. In 2013, almost three-quarters of all new visits of children to public health services were for an infectious disease, with respiratory infections the most common. Because of inconsistent data collection for some infections early in the period, the trend for infectious diseases as a whole cannot be estimated. However, there was a statistically significant downward trend in the proportion of new visits that were diagnosed as one of the 11 leading communicable diseases from 74.5% in 2005 to 62.1% in 2013 (P < 0.001). There was no difference in communicable disease patterns between provinces, but a higher per capita consultation rate was associated with a higher proportion of the leading infections (P = 0.008). Recent improvements in maternal health, hygiene, and preventive services may have had an impact in reducing the burden of infections.

اجتاهات معدالت حدوث األمراض املعدية بني األطفال يف أفغانستان يف وقت توسيع اخلدمات الصحيةحممد يارس أنور، جلربت بورهنام

اخلالصــة: تســتعرض هــذه الدراســة اجتاهــات معــدالت حــدوث األمــراض الســارية الشــائعة بــن األطفــال دون ســن اخلامســة يف أفغانســتان يف الفــرة بــن 2005 و2013. وتــم اختــاذ عــدد الزيــارات اجلديــدة لعيــادات املــرىض اخلارجــن ليكــون املقــام عنــد حســاب النســب. ويف عــام 2013 كان مــا يقــرب مــن ثالثــة أربــاع إمجــايل الزيــارات اجلديــدة التــي قــام هبــا األطفــال للخدمــات الصحيــة يف القطــاع العــام بســبب األمــراض

املعديــة، وكانــت األمــراض التنفســية هــي األكثــر شــيوعا. وبســبب عــدم التناســق يف مجــع البيانــات حــول بعــض األمــراض املعديــة يف وقــت مبكــر فــإن اجتــاه األمــراض املعديــة عــى وجــه اإلمجــال يتعــذر تقديرهــا. إال أنــه كان هنــاك اجتــاه متناقــص ذو أمهيــة إحصائيــة لنســب الزيــارات اجلديــدة التــي يتــم تشــخيصها عــى أهنــا أحــد األمــراض األحــد عــر الســارية الرئيســية، فبعــد أن كانــت %74.5 عــام 2005 أصبحــت 62.1% عــام 2013 (p < 0.001). ومل يكــن هنــاك فــرق يف أنــاط األمــراض الســارية بــن الواليــات، ولكــن معــدل االستشــارات لــكل نســمة ترافــق بنســبة أعــى مــع العــدوى الرئيســية (p = 0.008). إن جوانــب التحســن التــي طــرأت مؤخــرا عــى صحــة األمهــات وعــى النظافــة الشــخصية

وعــى اخلدمــات الوقائيــة قــد يكــون هلــا تأثــر يف خفــض عــبء العــدوى.

Tendances de l’incidence des maladies infectieuses chez les enfants en Afghanistan à l’heure de l’élargissement des services de santé publique

RÉSUMÉ La présente étude a étudié les tendances de l’incidence des maladies transmissibles les plus répandues chez les enfants de moins de cinq ans en Afghanistan entre 2005 et 2013. Les premières consultations en soins ambulatoires ont constitué le dénominateur pour calculer les pourcentages. En 2013, près de trois quarts de toutes les premières consultations d’enfants dans les services de santé publique avaient pour cause une maladie infectieuse, les infections respiratoires étant les plus fréquentes. Du fait d’une collecte des données incohérente pour certaines infections au début de la période d’étude, les tendances pour les maladies infectieuses dans leur ensemble ne peuvent être estimées. Pour autant, une tendance à la baisse statistiquement significative a été observée en ce qui concerne le nombre de premières visites pour lesquelles le diagnostic établi était l’une des 11 maladies transmissibles les plus répandues (74,5 % en 2005 contre 62,1 % en 2013, soit p < 0,0001). Aucune différence en termes de caractéristiques des maladies transmissibles n’a été établie entre les provinces, mais un taux de consultation plus élevé par habitant a été associé avec un pourcentage plus élevé pour les infections principales (p = 0,008). Les récentes améliorations en matière de santé maternelle, d’hygiène et de services de prévention ont pu avoir une influence sur la réduction de la charge des infections.

Trends in infectious disease incidence among children in Afghanistan at a time of public health services expansionM.Y. Anwar 1 and G. Burnham 1

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Introduction

Afghanistan has suffered from instabil-ity and conflict for the past 40 years. Al-most 36% of the population live below the poverty line (1) and access to public sector health facilities has historically been inadequate (2). In such a context, a high incidence of treatable diseases is to be expected. Children are particularly affected, not only because they are more vulnerable, but also because they con-stitute a large proportion of the Afghan population, of which 64% are under 24 years (2) and 17% under 5 years of age (3). The mortality rate for children under five years old is estimated to be 99 per 1000 live births, while the in-fant mortality rate is 71 per 1000 live births; with these rates, Afghanistan is 18th from last on the United Nations Children’s Fund (UNICEF) ranking of countries for child health (3). Chil-dren’s health is a sensitive reflection of the efficiency of the health services in a country.

In recent years, particularly since 2001, efforts have been made to expand public health services and increase ac-cess to them, as part of international cooperation to rebuild the country (4). Several studies have evaluated the association between these efforts and various health indicators, particularly in the areas of malnutrition, reproductive health, mortality and immunization, for both academic and planning purposes.

A less studied area is whether re-cent developments in Afghanistan have been associated with specific trends and characteristics of infectious diseases, particularly among children. While it is generally assumed that most diseases affecting children are communicable, precise numbers and trends have not been comprehensively studied, espe-cially in relation to the recent expansion of public health services. A few sources, such as the Multiple Indicators Cluster Surveys (MICS) and the Afghanistan National Household Surveys, contain sections on infectious disease morbidity,

but these are usually limited in scope. In the absence of systematic data, it is hard to calculate the prevalence of communi-cable diseases in the country.

The objective of this study was to assess trends in communicable diseases among children under five years of age, with particular attention to the most fre-quent infections, in light of recent efforts to invest in and expand public health services throughout the country. The results could provide some measure of the success of the efforts, as well as lessons for other similar undertakings.

Methods

The absence of a consistent health in-formation system prior to 2004 makes the historical study of disease patterns among children difficult. Thus, we considered only reports on patterns, characteristics, and trends in communi-cable disease among children attending public health facilities from 2005 to 2013. During this period, public health facilities expanded considerably. We used data from facilities implementing

the Basic Packages for Health Services (BPHS), which have been in place since 2002 (5). Nationally, nearly 80% of consultations for under-five-year-olds take place in these facilities (6). The number of such health facilities provid-ing BPHS increased from 1075 in 2004 to over 2000 in 2014 (7).

In the absence of a national census, we used the totals for all “new visit” con-sultations for children in BPHS facili-ties as the denominator for calculating proportions; this method is also used in the Ministry of Public Health’s Dis-eases Early Warning System (MoPH–DEWS) (8). The data set is managed by the Health Management Information System (HMIS) Department of the Ministry, which defines a “new visit” as a visit at which “a patient [is] diag-nosed with an episode of an illness for the first time”. Return visits for the same diagnosis within a predefined period were considered as re-attendance, and were excluded from our analysis. The diagnoses categorized as communica-ble diseases among children under five years of age in HMIS are listed in Box 1;

Box 1. Diseases categorized as communicable in HMIS records

1. Cold and cough (ARI)2. ENT (ear, nose, and throat) infection 3. Pneumonia (infectious) 4. Acute bloody diarrhoea 5. Acute watery diarrhoea 6. Diarrhoea with dehydration 7. Viral hepatitis 8. Measles 9. Pertussis

10. Diphtheria11. Tetanus (neonatal)12. Malaria 13. Urinary tract infection (UTI) (all types)14. Gastrointestinal tract worms15. Skin infections16. Eye infections17. Severely ill (infections with severe symptoms, not classified in other

categories)

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classification is based on clinical mani-festations.

We used data from 2013 to assess disease trends, seasonal fluctuations, and distribution by province. We then analysed trends in some key diseases between 2005 and the end of 2013. Data analyses were performed with STATA statistical software (v.12) and Excel (v.2013). Linear regression analy-sis was used to evaluate the significance of associations. Reports from the World Health Organization, UNICEF, the United States Agency for International Development, and the Afghanistan MoPH were consulted for comparison.

Results

Monthly data returns for 2013 reported 13 404 322 new visits of children less than five years old to BPHS facilities for all conditions. Of these, 9 678 477 (72%) were diagnosed as having a com-municable disease (Table 1). Among all first visits for communicable disease, respiratory infection was the most fre-quent diagnosis, with 2 610 013 cases of acute respiratory infection (ARI) (27%) and 1 067 017 of pneumonia (11%). Diarrhoea, ear, nose and throat infection, urinary tract infection, and malaria were the next most frequently reported infectious diseases.

There were no statistically sig-nificant seasonal fluctuations in the

overall proportion of diagnoses of com-municable diseases in 2013, although respiratory infections peaked around December–March (winter), diarrhoea in June–August (summer), and malaria in June–September. The total number of first visits to outpatient departments of public health facilities by children under five years increased from 2 883 736 in 2005 to 13 404 322 in 2013 (Table 2), as a result of the expansion of the health infrastructure in Afghanistan during this period (7). From 2005 to 2010, there was an apparent downward trend in the proportion of first visits that were for communicable disease, which reversed after 2010 (Figure 1). This may reflect a change in the reporting forms in 2010 to include specific communicable diseases that had previously been recorded as “others”, e.g. eye infections, intestinal worms, skin diseases, and oral–dental infections. This inconsistent record-ing of data means that no statistically significant trend can be distinguished in the proportion of new visits classified as communicable diseases, over the period 2005–13 (Table 2).

There was, however, a statistically significant downward trend in the pro-portion of new visits that were classi-fied as one of the infections for which there was continuous reporting, in particular the 11 leading infections (P < 0.001). Overall, the average decrease was around 1.8% per year (Table 3). Further breakdown of the data showed

a reduction in the incidence of all these diseases, except ARI and measles (Ta-ble 3 and Figure 2). Malaria showed the most dramatic fall. Statistically similar patterns were seen in girls and boys.

Similar patterns of the leading infec-tions were found in the different prov-inces, despite differences in climate and in socioeconomic and other character-istics. From 2008 to 2011 (9), higher consultation rates in provinces were positively correlated with higher pro-portions of visits for the leading com-municable diseases (an average of 2.5% increase for each point increase in per capita consultation rate (P = 0.008)).

Discussion

Our results show that respiratory infec-tions account for the biggest share of all new visits to public health facilities by children under five years. The finding is in line with previous studies (8,10); of 247 216 deaths reported among children under five in Afghanistan in 2008, 72 716 (29.4%) were attributed to pneumonia (11). Afghanistan is part of the list of those few countries that account for half of pneumonia-related deaths among children (11). How-ever, despite continuing to be the most widespread disease among children, our analysis indicates a statistically sig-nificant reduction in the proportion of diagnoses of pneumonia between 2005

Table 1 Communicable diseases diagnosed in children aged under 5 years at health facilities in Afghanistan, 2013

Total number of new visits 13 404 322

No. of diagnoses of communicable disease (% of all new visits) 9 678 447 (72.2%)

No. of diagnoses of specific infectious diseases (% of all infectious diseases)

ARI 2 610 013 (27.0%)

Diarrhoea 2 581 053 (26.7%)

ENT infection 1 708 129 (17.6%)

Pneumonia 1 067 017 (11.0%)

Urinary tract infection 224 727 (2.3%)

Malaria 43 347 (0.4%)

Other 1 444 161 (15.0%)

ARI = cold and cough

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and 2013. There may be several possible explanations for why incidence rates are falling while mortality remain high for respiratory infections. It may be that many cases are not reported to the da-tabase that we used, but are accounted for through other means (remembering that there are considerable areas where there are still no regular services). Or it could be that, in the information system, children who die from pneumonia are categorized as severely ill patients, using the Integrated Management of Child-hood Illnesses (IMCI) classification, and may be reported separately on an IMCI form (12). Therefore, while there may have been a modest reduction in pneumonia, as found also in another recent study (8), the apparent dramatic decrease in morbidity rates found here should be viewed with great caution.

In general, the findings indicate that almost three-quarters of all new visits of children to public health facilities are for communicable diseases. Reports from DEWS indicate that the proportion of communicable disease diagnoses in all outpatient departments in public sector facilities for all age groups is between 60% and 80% (8). This suggests that, whatever the trends, the burden of com-municable diseases in Afghanistan is still very great.

Although no association was found between geographical location and

burden of infections among children, we found that the higher the per capita consultation rate, the higher the pro-portion of diagnoses for the leading 11 communicable diseases among chil-dren. It is likely that, in rural provinces, consultation rates in the public sector facilities are higher, as there is a pau-city of private clinics in these areas. It may also be that larger family sizes in rural areas create a higher demand for paediatric care. A report in 2014 found a higher risk of death from infectious

causes among children in remote rural areas, consistent with our analysis (13). It is interesting that no difference was observed in the proportion of infec-tions among boys and girls, contrary to popular perception that boys are more vulnerable.

The incidence of the leading infec-tious diseases appears to be declining. Similarly, the DEWS reported a reduc-tion in communicable diseases among the general population from 2007 to 2013, comparing their annual reports in

80

75

70

65

Com

mun

icab

le d

isea

ses

as %

of a

ll ne

w v

isits

Year

2006 2008 2010 2012

Figure 1. Communicable disease diagnoses among children under 5 years, as percentage of all new visits, reported from health facilities (monthly reports), January 2005 to December 2013

Table 2 Diagnoses in children under 5 years attending health facilities in Afghanistan, 2005–2013

Year Communicable disease Other conditions Total new consultations P value

2005 2 168 226 (75.2%) 715 510 (24.8%) 2 883 736 –

2006 3 137 87 (74.7%) 1 059 956 (25.3%) 4 197 342 –

2007 3 737 258 (74.1%) 1 305 145 (25.9%) 5 042 403 –

2008 5 077 243 (71.2%) 2 056 401 (28.8%) 7 133 644 –

2009 6 041 342 (69.3%) 2 678 126 (30.7%) 8 719 468 0.1171

2010 6 629 445 (67.9%) 3 133 727 (32.1%) 9 763 501 –

2011 7 900 573 (70.1%) 3 375 465 (29.9%) 11 276 038 –

2012 8 675 290 (72.8%) 3 238 986 (27.2%) 11 914 276 –

2013 9 678 447 (72.2%) 3 725 875 (27.8%) 13 404 322 –

Total 53 045 540 (71.4%) 21 289 190 (28.6%) 74 334 730 N/A

Boys 27 428 378 (71.8%) 10 748 401 (28.2%) 38 175 279 0.157

Girls 25 617 162 (70.8%) 10 540 789 (29.2%) 36 156 416 –

1 P value is for annual trend.

EMHJ • Vol. 22 No. 11 • 2016 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale

782

Tabl

e 3

Inci

denc

e of

11

lead

ing

com

mun

icab

le d

isea

ses

amon

g ch

ildre

n un

der 5

yea

rs m

akin

g a

new

vis

it to

a B

PHS

faci

lity,

20

05-

2013

Year

200

520

06

200

720

08

200

920

1020

1120

1220

13Tr

end

P va

lue1

Tota

l no.

of n

ew v

isits

2 88

3 73

64

197

342

5 0

42 4

03

7 13

3 64

48

719

468

9 76

3 50

111

276

038

11 9

14 2

7613

40

4 32

2N

/AN

/A

11 le

adin

g co

mm

unic

able

di

seas

es, n

o.

(% o

f all

new

vis

its)

2 15

0 7

77

(74.

58)

3 11

1 946

(7

4.14

)3

712

426

(73.

62)

5 0

41 4

90

(70

.67)

6 0

02

353

(68.

84)

6 58

7 97

7 (6

7.48)

7 40

4 86

5 (6

5.67

)7

488

711

(62.

85)

8 25

5 85

9 (6

1.59)

- 1.8

%2

<0.0

01

All

othe

r cas

es73

2 95

91 0

85 3

961 3

29 9

772

092

154

2 71

7 11

53

175

524

3 87

1 173

4 42

5 56

55

148

463

N/A

N/A

Dis

ease

inci

denc

e, n

o. o

f cas

es (i

ncid

ence

per

100

00

0 n

ew a

tten

dees

und

er 5

yea

rs)

Dia

rrho

ea76

4 63

1(2

6 51

5.2)

1 064

029

(25

350

.0)

1 217

259

(24

140

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1 70

5 81

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(23

912.

3)1 8

62 0

92(2

1 355

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2 0

99 18

6(2

1 499

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2 34

7 59

7(2

0 8

06.

7)2

285

600

(19

160

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581 0

53(1

9 25

1.2)

- 90

530

.00

6

ARI

529

676

(18

367.7

)80

4 39

8(1

9 16

4.4)

982

439

(19

483.

5)1 3

91 5

56(1

9 50

6.9)

1 841

996

(21 1

25.1)

1 970

112

(20

177.7

)2

229

129

(19

756.

7)2

334

320

(19

568.

5)2

610

013

(19

467.3

)+

4.23

0.3

18

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hthe

ria11

0(3

.8)

54 (1.3)

34(0

.7)

93 (1.3)

124

(1.4)

62(0

.6)

331

(2.9

)39

6(3

.3)

180

(1.3)

- 0.13

0.7

75

ENT

infe

ctio

n37

7 97

0(1

3 10

6.9)

566

723

(13

501.9

)69

5 44

7(1

3 79

1.9)

954

228

(13

376.

4)1 1

61 4

77(1

3 32

0.5

)1 3

17 8

26(1

3 49

7.0)

1 472

699

(13

052

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1 543

689

(12

940

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1 70

8 12

9(1

2 74

0.4

)- 8

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0.0

96

Mal

aria

64 9

41(2

252.

0)

76 6

09

(182

5.2)

83 3

11(1

652.

2)97

930

(137

2.8)

72 0

34(8

26.1)

80 0

82(8

20.2

)83

954

(744

.1)63

143

(529

.3)

43 3

47(3

23.3

)- 2

153

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04

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sles

1166

(40

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2692

(64.

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01

(35.

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6.7)

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0.8

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02

(85.

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7)15

186

(127

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4268

(31.8

)+

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0.5

68

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ussi

s18

88(6

5.5)

260

7(6

2.1)

4044

(80

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260

7(3

6.5)

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(22.

3)23

07

(23.

6)35

71(3

1.6)

360

6(3

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)15

60(1

1.6)

- 6.4

30

.775

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mon

ia34

9 24

8(1

2 11

0.9

)50

321

6(1

1 988

.9)

625

595

(12

406.

7)74

5 52

0(1

0 4

50.8

)88

5 47

4(1

0 15

5.1)

91 7

658

(9 3

98.6

)1 0

48 2

93(9

291.0

)1 0

34 8

81(8

675

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1 067

017

(795

8.5)

- 567

30

.00

8

Susp

ecte

d tu

berc

ulos

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09

(232

.6)

7630

(181

.8)

6920

(137

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9111

(127

.7)

12 0

22(1

37.9

)86

78(8

8.9)

10 6

82(9

4.7)

7127

(59.

7)85

43(6

3.7)

-183

0.0

07

Urin

ary

trac

t inf

ectio

n52

446

(181

8.7)

79 0

86(1

884.

2)91

696

(181

8.5)

127

036

(178

0.8

)15

5 77

3(1

786.

5)17

7 32

1(1

816.

1)19

4 95

6(1

727.9

)19

5 31

7(1

637.3

)22

4 72

7(1

676.

2)- 2

730

.00

9

Vira

l hep

atiti

s19

92.0

(69.

1)49

02.

0(1

16.8

)38

80.0

(76.

9)49

75.0

(69.

7)41

16.0

(47.2

)64

43.0

(66.

0)

500

3.0

(44.

3)54

46.0

(45.

7)70

22.0

(52.

4)- 5

.53

0.0

32

1 P v

alue

for t

rend

. 2 P

erce

ntag

e de

crea

se p

er y

ear.

3 Ave

rage

ann

ual c

hang

e in

inci

denc

e am

ong

new

atte

ndee

s.

ARI =

cold

and

coug

h; B

PHS

= ba

sic

pack

ages

for h

ealth

serv

ices

; EN

T =

ear,n

ose,

thro

at in

fect

ion

املجلد الثاين و العرشوناملجلة الصحية لرشق املتوسطالعدد احلادي عرش

783

this period based on assessment of a wider datasets. Another study reported that the proportion of disability-adjust-ed life years (DALYs) attributable to communicable and neonatal diseases was 48.9% in 2010, a reduction of 20% from 1990 (14). Thus, as suggested by these other sources, there may be a real downward trend in some important childhood infections, if not in all.

It is plausible that efforts to improve the public sector health services in Afghanistan since 2002 have contrib-uted to the reduction in pneumonia and other communicable diseases in the country (15). These investments, aimed at improving service delivery, especially for women and children (16), have produced results that may be associ-ated with reduced childhood morbidity,

including: a reduction of almost three-quarters in the maternal mortality rate (17), which is attributed to better antenatal and postnatal care (18); an increase of 4000% in the number of births attended by a skilled birth atten-dant (7); and improved family planning services (19). Another relevant devel-opment may be the improvements in water supply, sanitation and hygiene.

The MICS survey in 2010–11 found that 57% of the population had access to clean water and hygiene, a substantial improvement compared with the early 2000s (20). According to field studies, better access to clean water is the reason for the reduced incidence of diarrhoea and typhoid (8). A study in Wardak province demonstrated that a water and hygiene intervention resulted

in a 40% reduction in diarrhoea-related illness (21). Improved water and sanita-tion may also be associated with the reduction in outbreaks of viral hepatitis, which is mostly transmitted through contaminated food and water (22). Other contributory factors could be the wider implementation of preven-tive measures and control programmes, such as vaccination campaigns and distribution of insecticide-treated nets (ITNs), which are credited with reduc-ing the incidence of poliomyelitis and malaria, respectively (8). In some parts of Afghanistan, up to 75% of the popula-tion uses ITNs (23).

We found some reports of circum-stances that could potentially or actu-ally hinder efforts to reduce the burden of childhood infections. These include

Figure 2. Trends in diagnoses of 11 leading infections (incidence per 100 000 new visits) among children under 5 years attending health facilities, 2005-2013

EMHJ • Vol. 22 No. 11 • 2016 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale

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inadequate vaccine coverage. In the case of measles, the coverage was reported by different sources to be as low as 44% in the second quarter of 2012 (24), 62% in 2011 (3) and 56.7% in 2010/11 (20). Continued insecurity and a low level of education among women, particularly in rural areas (8), may have hampered vaccination efforts. Such low coverage in a context of high birth rates can only mean frequent outbreaks, which may also have distorted the trends in mea-sles and poliomyelitis in our analysis. The high rate of malnutrition among children (25), a consequence of food insecurity (26), poor economy, extreme weather conditions, and ongoing con-flict, may further contribute to mor-tality rates. The interaction between malnutrition and childhood infections (27), which results in a vicious cycle of more infections, makes it harder to tackle the burden of infections. While the fertility rate in Afghanistan is falling, the birth rate is still high compared with other countries in the region, at 39–48 per 1000 population (28). With high fertility rates, it is harder to reduce the burden of some infections, e.g. measles, as has been observed in other regions of the world (29). Furthermore, a shortage of qualified health professionals adds to the challenge (2).

Limitations of resultsOur main source of information for this study was reports to the HMIS, which started collecting data in 2003. The data are not collected under the rigorous conditions typically applied to designed studies. The majority of cases are diagnosed and reported on the basis of clinical manifestations; thus, incor-rect classification, resulting in over- or under-reporting, is an occasional prob-lem (30).

Another limiting factor is the dif-ficulty of establishing reference points and denominators for morbidity rates, because of the lack of national census data. For this reason, we chose to use proportions rather than rates, and chil-dren attending outpatient departments as the denominator, rather than those in the general population. This might not reflect health service use by some parts of the population, e.g. those who prefer to use the private sector, which is not regulated and does not contribute data to the national system (31). It is pos-sible that higher-earning groups have lower incidence rates of disease.

Conclusion

While children are still affected by a high burden of infectious diseases, the picture

is gradually improving for at least a few key communicable diseases. Although it is hard to attribute the observed results to specific factors, recent progress in maternal health, access to clean water and hygiene, and wider implementation of control programmes – all as a result of recent public health programmes – may have been associated with the reduction in infectious diseases among children. However, if the momentum is to be sustained, policy-makers and health planners need to address remain-ing challenges, through continued in-vestment in quality health services and infrastructure, especially in areas such as vaccine coverage, food security, aware-ness of hygiene and nutrition, training of health personnel, and programme monitoring.

Acknowledgements

We thank the Ministry of Public Health of Afghanistan for allowing us access to their database; particular thanks go to Dr Sayed Yaqoob Azimi, Head of the HMIS Department, and to Dr Wudod Safi, Consultant to the HMIS Depart-ment.Funding: None.Competing interests: None declared.

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1Epidemiology and Biostatistics Department, School of Public Health,Tehran University of Medical Sciences, 2Knowledge Utilization Research Center 3Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran 4Hematology and Medical Oncology Department, Cancer Research Center, Cancer Institute of the Islamic Republic of Iran, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 5Mental Health Reearch Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Islamic Republic of Iran. (Correspondence to: S. Nedjat: nejatsan@sina.tums.ac.ir).

Received: 24/08/15; accepted: 26/07/16

Self-reported versus proxy reported quality of life for breast cancer patients in the Islamic Republic of IranF. Najafi, 1 S. Nedjat, 1,2 K. Zendehdel, 3 M. Mirzania 4 and A. Montazeri 5

ABSTRACT Since quality of life (QoL) is subjective, self-reported QoL is the main source of assessment; however, in some situations the patient cannot evaluate his/her own status. In this cross-sectional study, 148 patients with breast cancer referred to the Cancer Institute of the Islamic Republic of Iran and their caregivers were selected through the consecutive sampling method. Five oncologists from this centre also evaluated the QoL of these patients. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire was completed by these 3 groups and the results compared. The patient–caregiver intra-class correlation coefficient (ICC) for all 15 QLQ.C30 domains was moderate to good (ICC = 0.41–0.76). Agreements between QoL scores of patients and those of oncologists were moderate to good, except in the 4 domains. In the patient–caregiver comparison there was 55% exact agreement, and for the patient–physician comparison agreement was 45%. The findings can be used in the patients’ decision-making process and care planning when patients with breast cancer are unable to self-report the QoL.

جودة احلياة باإلبالغ الذايت مقابل اإلبالغ عرب وسيط لدى املصابات برسطان الثدي يف مجهورية إيران اإلسالميةفرشته نجفي، سحرناز نجات، كاظم زنده دل، مهرزاد مريزانيا، عيل منتظري

اخلالصــة: نظــرا لكــون جــودة احليــاة أمــر يقــرره الشــخص نفســه، فــإن اإلبــاغ الــذايت عنــه هــو املصــدر الرئيــي للتقييــم، إال أن هنــاك بعــض احلــاالت التــي ال يســتطيع فيهــا املريــض تقييــم وضعــه. ويف هــذه الدراســة املقطعيــة التــي شــملت 148 مصابــة برسطــان الثدي ممن تــم حتويلهــن إىل معهــد الرسطان يف مجهوريــة إيــران اإلســامية ، والــايت تــم اختيــار القائمــن عــى تقديــم الرعايــة الصحيــة هلــن بطريقــة االختيــار التتابعــي. ولقــد قــام مخســة اختصاصيي أورام يعملــون يف هــذا املعهــد بتقييــم جــودة حيــاة هــؤالء املريضــات أيضــا. وقــد اســتكملت املجموعات الثاث اســتبيان جــودة احليــاة للمنظمــة األوربية لبحــوث ومعاجلــة الرسطــان، ومتــت مقارنــة النتائــج. واتضــح أن معامــل الرتابــط داخــل األصنــاف للمــرىض وللقائمــن عــى تقديــم الرعايــة الصحيــة هلــم لــدى مجيــع املجــاالت يف االســتبيان وعددهــا 15 جمــاال يــرتاوح بــن متوســط وجيــد )معامــل الرتابــط = 0.76 - 0.41(. وكانــت مواطــن التوافــق بــن مقاييــس جــودة احليــاة لــدى املــرىض ولــدى اختصــايص األورام تــرتاوح بــن متوســطة وجيــدة، باســتثناء 4 جمــاالت. ويف جمــال املقارنــة بــن املريضــات والقائمــن عــى تقديــم الرعايــة كان هنــاك %55 مــن التوافــق التــام، وكان هنــاك %45 مــن التوافــق بــن املريضــات واألطبــاء. ويمكــن االســتفادة مــن هــذه النتائــج يف عمليــة اختــاذ املــرىض للقــرارات ويف التخطيــط للرعايــة عندمــا ال يكــون بمقــدور املصابــات برسطــان الثدي اإلبــاغ الــذايت عن جــودة حياهتن.

Qualité de vie auto-évaluée et évaluée par un tiers pour des patients atteints d’un cancer du sein en République islamique d’Iran

RÉSUMÉ La qualité de vie étant de nature subjective, l’auto-évaluation constitue l’instrument de choix pour la mesure de celle-ci. Pour autant, dans certaines circonstances, le patient n’est pas capable d’évaluer sa situation. Au cours de cette étude transversale, 148 patients adressés à l’Institut du Cancer de République islamique d’Iran pour un cancer du sein ont été sélectionnés avec leurs aidants à l’aide d’une méthode d’échantillonnage consécutif. Cinq oncologues travaillant dans ce centre ont également évalué la qualité de vie de ces patients. Le questionnaire Qualité de vie (QLQ) de l’Organisation européenne pour la Recherche et le Traitement du Cancer a été rempli par ces trois groupes et les résultats ont fait l’objet d’une comparaison. Le coefficient intra-classe (CIC) patient-aidant pour les 15 domaines du QLQ-C30 allait de modéré à bon (CIC= 0,41-0,76). La concordance entre les scores des patients portant sur la qualité de vie et ceux des oncologues étaient compris entre « modéré » et « bon », excepté dans quatre domaines. La comparaison patient-aidant donnait une concordance exacte dans 55 %, et la comparaison patient-médecin une concordance de 45 %. Les résultats peuvent être utilisés au cours du processus de décision clinique et de planification des soins quand les patients atteints d’un cancer du sein ne sont pas en mesure d’évaluer eux-mêmes leur niveau de qualité de vie.

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Introduction

Quality of life (QoL) is considered an important outcome in both health research and cancer research. It has been measured to evaluate the effects of various curative and palliative treat-ments, to assess the function of patients in different domains and as a criterion for clinical decision-making (1–5). The World Health Organization defines QoL as "an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" (6,7).

Since QoL, a subjective concept, shows the person’s perception of his own health status and other aspects of life, it should be self-reported. In other words, the patient is the main source of QoL assessments (3,8,9). However, there are situations in which the patient is not able or does not want to prop-erly respond to the QoL questions. For instance, in patients with cognitive or mental disorders or in patients with seri-ous diseases like cancer where conduct-ing the interviews is not physically or mentally feasible, proxy-reported QoL has been suggested (5,8,10–12). Pa-tients with breast cancer who participate in QoL studies may not be able or may not wish to provide sufficient and valid information for self-reported QoL as-sessment. In these cases, the proxies that are in direct contact with the patient can be considered potential substitutes for self-evaluation (12,13). The main ques-tion is how close these evaluations are to the patient’s self-reported evaluation (3,10,14–16). Caregivers and health care providers are considered main candidates for the role of proxy. There are contradictory findings about QoL assessments by physicians: some stud-ies show good patient–physician agree-ment (9,14,17), while others do not (3,18). On the other hand, caregivers such as a partners, parents or children may provide a more valid evaluation

of the patient’s QoL since they have a longer and closer contact with, and more understanding of, the patient (8,10–22).

The characteristics of both patient and proxy, e.g. sex, age, education, the relationship between them and the contact frequency can affect agreement (8,15,21,23). This investigation, there-fore, was designed to establish whether physicians or caregivers could be valid proxies for the self-assessment of QoL. As QoL is a culture-dependent concept and has different definitions in differ-ent countries, information obtained from other parts of the world cannot be used for our Region. To the best of our knowledge, there is no evidence from the Islamic Republic of Iran and the Eastern Mediterranean Region showing that agreement between self-reporting and proxy-reporting of QoL for breast cancer patients and their characteristics has been assessed.

The objective of our study was to de-termine whether QoL assessments by proxies (caregivers and physicians) are in agreement with self-reported QoL for breast cancer patients. The correla-tions between the scores obtained by the proxies and the patients themselves were calculated. The absolute level and direction of differences between the ratings was estimated. We also aimed to explore the association between patient and proxy demographic characteristics and agreement.

Methods

Study population and samplingThe study was conducted from June to December 2014. The study population comprised patients who had been re-ferred to the medical oncology clinic of the Cancer Institute of the Islamic Re-public of Iran and had been diagnosed by pathology tests as having breast cancer at least 2 months previously. The inclusion criteria were lack of any

mental disorders which could interfere with answering the questionnaires, knowing Farsi, and not being involved in any other study. Patients should have completed at least 2 chemotherapy sessions because of the acute changes to QoL during the first 2 sessions. It should be noted that chemotherapy was conducted on more than 96% of the patients of the Cancer Institute; only those with very small tumours did not undergo chemotherapy. Thus, because of the availability of the chemotherapy patients, they were considered the study population. A consecutive sampling method was applied, i.e. every patient meeting the inclusion criteria was se-lected till the required sample size was achieved. The sample size was calcu-lated as 148 pairs of patients–caregivers using the common statistical formula

2

21

212 )(2

d

ZZn

βασ −−+

=

where d = 7, σ = 21 and β = 0.80, with type I error of 5%. We considered in-home caregivers who were the pa-tients’ family members or relatives in this study, not the facility-based caregiv-ers. The caregivers were asked to fill out the questionnaires independently. Each patient’s oncologist was also requested to complete the questionnaires inde-pendently.

Study toolsThe QoL was evaluated using the Farsi language third version of the European Organization for Research and Treat-ment of Cancer Quality of Life Ques-tionnaire (EORTC QLQ-C30) (24).

This questionnaire consisted of 30 items (28 4-point items and 2 7-point items on visual analogue scales) on 5 functional scales (physical, role, cog-nitive, emotional, social), 3 symptom scales (fatigue, nausea and vomit-ing, pain), 6 single items (dyspnoea, insomnia, appetite loss, constipation, diarrhoea, financial difficulties) and a global health status/QoL scale. In line

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with EORTC guidelines, all scales and single items were scored 0–100. On the functional and global QoL scales, higher scores indicate better QoL, while on the symptom scales higher scores show a higher level of problems and symptoms (25).

Demographic questionnaireThe patients’ demographic variables covered age, marital status, education and self- reported social status (5-point Likert scale). Disease stage was ob-tained from the patients’ files.

The caregivers’ demographic infor-mation included age, sex, education, relationship with patient and the num-ber of hours per day spent caring for the patient.

The caregivers and physicians were asked to review the patient’s situation and answer the QLQ-C30 whose ques-tions had been changed to third-person to evaluate the patient’s QoL.

Statistical methodsThe statistical analysis was conducted using SPSS, version 20, and STATA, version 12.

The descriptive analysis of the data was done to obtain the mean and stand-ard deviation (SD) of the questionnaire scales in the 3 study groups.

To determine level of agreement between the study groups, intra-class correlation coefficients (ICCs) for pa-tient–caregiver and patient–physician were estimated (26). An ICC ≤ 0.40 was considered poor, 0.41–0.60 mod-erate, 0.61–0.80 good and 0.81–1.00 excellent agreement (5,27).

The mean absolute patient–proxy differences for 15 QLQ-C30 measures was calculated, not considering the di-rection of differences. The mean for directional differences was also calculat-ed, presenting the bias in proxy scores. Significant differences from zero in di-rectional mean scores were determined by paired t-tests and interpreted as sys-tematic bias in proxy QoL evaluations

(5,28–30). We also determined 95% confidence intervals (CI 95%).

The directional mean scores were standardized by dividing them by their SD. They were interpreted as the Co-hen's d effect (0.2 = small, 0.5 = moder-ate and 0.8 = large bias) (31).

The magnitude of the exact response agreement and differences of more than one response category (large patient–proxy discrepancies) were calculated for each question: if the 3 raters chose

exactly the same response category for each question, complete agreement was reported (3).

The association between patient–proxy agreements and characteristics was assessed using simple and mul-tiple linear regression. Absolute and directional differences in global health status/QoL scores were considered dependent variables while the patient’s and proxy’s characteristics were consid-ered independent variables. All variables

Table 1 Characteristics of patients and caregivers (n = 148)

Characteristic Caregivers Patients

No. % No. %

Sex

Female 79 53.4 148 100.0

Male 69 46.6 0.0 0.0

Education

Illiterate 6 4.1 35 23.6

Primary school 25 16.9 68 45.9

Secondary school 94 63.5 39 26.4

University level 23 15.5 6 4.1

Marital status

Married 104 70.3 113 76.4

Single 39 26.4 10 6.8

Divorced 3 2.0 3 2.0

Widowed 2 1.4 22 14.9

Disease stage*

In situ – –- 10 7.1

Local – – 64 45.7

Local/regional – – 56 40.0

Advanced – – 10 7.1

Relationship to patient

Spouse 57 38.5 – –

Child or parent 53 35.8 – –

Brother or sister 24 16.2 – –

Other relative 14 9.5 – –

Living situation

Same household 96 64.9 – –

Not same household 52 35.1 – –

Subjective socioeconomic status

Poorest – – 4 2.7

Poor – – 50 33.8

Intermediate – – 77 52.0

Rich – – 15 10.1

Richest – – 2 1.4

*No. varies owing to missing data.

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with P-value < 0.2 in the simple linear regression analysis were included in the regression model simultaneously (32). Variables with P< 0.05 were considered statistically significant.

Ethical considerationsParticipation in the study was com-pletely voluntary. The objective of the study was explained to respondents and they were informed that their decision about taking part in the study did not have any effect on their treatment by the medical team member, and also that their responses would be kept confidential. The project was reviewed and approved by Tehran University of Medical Sciences ethics committee (Project number: 9111111013).

Results

Of 168 patients approached, 155 con-sented to participate in the study (92% response rate). The reasons for refusing to participate were lack of time or inter-est. Seven caregivers did not agree to take part. All 5 oncologists also took part in the study. Thus, the final analysis was conducted on 148 patient/proxy pairs.

The characteristics of patients and caregivers are presented in Table 1. More than 90% of caregivers were family members, with about 65% living in the same household as the patient. The mean age of patients was 47.6 (SD 10.1) years and for caregivers it was 37.6 (SD 10.2) years. The average duration of schooling for patients was 5.9 (SD 4.7) years and for caregivers it was 10.8 (SD 3.9) years. The mean time since diagnosis was 17.2 (SD 1.4) months. The mean duration of in-home care was 16.3 (SD 8.3) hours.

Table 2 shows the mean QLQ-C30 scores for patients from their own and from the proxies’ point of view. The factor with the highest mean score on the symptom scale was financial difficul-ties according to all 3 groups. On the functional scale, cognitive functioning

gave the highest score in the viewpoint of patients and physicians while the caregivers scored role functioning high-est. Patients scored global health status lower than the physicians and caregiv-ers.

The correspondence between pa-tients’ and proxies’ scores is shown in Table 3. The patient–caregiver agree-ment was not classed as weak on any of the scales (ICC < 0.40), while on the cognitive function, role function, insomnia and diarrhoea scales, the pa-tient–physician agreement was weak.

For patient–caregiver, the mean absolute difference ranged from 9.96 to 21.40; for patient–physician this was 15.59 to 24.55 (Table 3). The mean patient–caregiver directional difference ranged from –5.01 to 6.53 and for pa-tient–physician it was between –7.16 and 7.21.

The caregivers reported statistically significantly lower levels of QoL for patients for cognitive function, social function and fatigue compared with the patients’ reports, while the patients’ emotional function QoL was signifi-cantly higher from the caregivers’ point of view.

The differences in the QoL reports of patients and physicians were statisti-cally significant on 11 scales, with the emotional function and global health status/QoL of the patients significantly better in the physicians’ viewpoint (Ta-ble 3).

Patient–proxy Cohen's d-values ranged from small to moderate (Table 3).

We used 4144 comparisons (28 questions × 148 cases) to calculate the “exact response category” and “large patient–proxy discrepancies”. The exact response agreement, i.e. the proportion of cases for which 2 raters had chosen exactly the same response category, was 55.0% (2291) for patient–caregiver and 45.0% (1870) for patient–physician re-ports. Complete agreement (i.e. 3 raters choosing exactly the same response

category) was 27.5% (1143). Large pa-tient–caregiver discrepancy was seen in 6.5% (271) of cases; this discrepancy was 10.1% (419) for patient–physician.

Association between patient–proxy agreement and patients’ and proxies’ characteristicsNone of the variables had a significant association with the patient–caregiver agreement on the Global Health Sta-tus/QoL in the simple linear regression analysis (Table 4). In the multiple linear regression, the only significant variable was patients’ age. i.e. older age was asso-ciated with a greater absolute difference.

In both simple and multiple linear regression, the longer the duration of schooling, the lower the directional dif-ference (Table 4).

Patient–physician agreement on the Global Health Status/QoL scoreIn the simple linear regression analysis, directional difference was statistically significantly greater with older age of the patient. None of the variables was significantly associated with absolute difference in the simple and multiple linear regression (Table 4).

Discussion

This study compared the QoL rating of patients with breast cancer receiving chemotherapy with that estimated by caregivers and physicians using the EO-RTC QLQ. We found that the none of the ICCs between the patients and car-egivers were ≤ 0.40 (weak agreement) on all scales (ICC range: 0.41–0.76). In a study on cancer patients in the Netherlands using the same question-naire, the ICC range was 0.46–0.73 and the lowest agreement was reported for insomnia (5). The greatest absolute difference in our study was 21.4 on the insomnia scale, which was in accord-ance with the findings of the Nether-lands study (5). The severity of pain, dyspnoea and nausea compared with

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the severity of sleep problems could be the reason for the better agreement.

In the patient–physician rating, agreements were generally moderate. The only 2 scales with good patient–physician agreement were fatigue and constipation. These were in line with the findings of Blazeby et al. in a study conducted in the United Kingdom on 52 oesophageal cancer patients (33). In that study, there was weak patient–phy-sician agreement on certain scales, in-cluding insomnia, cognitive functional, and diarrhoea; the strongest agreement was seen for the pain scale, similar to our findings. In accordance with some other studies, patient–physician agreement for the symptom scales was greater than for the functional scales (3,33). The physicians appear to pay more atten-tion to clinical problems and the com-plications caused by treatment, while patients’ daily activities, concentration and entertainment, covered in the role and cognitive functional scales, do not appear to have so much importance to them. Cognitive function and role function are the personal experiences of patients, which physicians cannot observe routinely. Since all our patients were non-hospitalized, physicians could not observe them long enough. Since the caregivers can see and feel the pa-tients’ daily activities and problems, they have non-clinical viewpoints, and hence different kinds of agreements.

Directional differences show that the caregivers reported a worse situation for the patients in the physical, role functional, emotional and global health scales, considering the negative directional differences. The highest di-rectional difference was –5.01 for the emotional scale. These are in line with the findings of Sneeuw et al. in the Neth-erlands (5).

On the emotional scale, the physi-cians overestimated the patients’ QoL status, while on the 9 other scales they underestimated the status. Generally in our study and in other research (5), most differences were seen in the more Ta

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املجلد الثاين و العرشوناملجلة الصحية لرشق املتوسطالعدد احلادي عرش

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subjective scales, particularly in the emotional scale. The higher score given by proxies for the emotional scale shows that the mental status of patients appears better than their own estimates.

Large patient–proxy dis-crepancies were seen for 6.5% of patient–caregiver and for 10.1% of patient–physician comparisons. These are much lower than the findings of Sneeuw et al. using the Dart-mouth COOP Functional Health Assessment charts/WONCA (3), who reported 17% and 18% respectively. The different study tools are probably the main reason for this discrepancy: COOP/WONCA is a more compact tool while QLQ-C30 is more in line with the Iranian culture.

In accordance with the find-ings of Sneeuw et al. (5), there was no significant association between patient–proxy differ-ences and demographic vari-ables using regression analysis.

It is important to point out that there is no gold standard for QoL estimations, therefore we cannot always consider the proxy estimation to be wrong and those of the patients to be correct. In fact, some of these differences were related to the differences between objective health, which was assessed as better by proxies, and subjec-tive health, which was assessed as better by patients, and was considered the same as QoL.

Study limitationsOne of the study limitations was that very sick patients could not participate in our study, al-though in practice we do need to use proxy QoL estimation for these patients.Ta

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EMHJ • Vol. 22 No. 11 • 2016 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale

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The caregiver’s burden and health status are important variables which were not assessed in our study although they can affect the associations we measured.

Considering the the greatest pa-tient–proxy discrepancy was on the emotional scale, it was suggested that patients with a wide range of mental health considerations be included in fu

Table 4 Simple and multiple linear regression on the differences of global health status/QOL score between patient–caregivers and patient–physician (n = 148)

Directional differenceAbsolute differenceCharacteristic

Patient–physicianPatient–caregiverPatient–physicianPatient–caregiver

Adjusted βCrude βAdjusted βCrude βAdjusted βCrude βAdjusted βCrude βPatients

0.180.31*0.020.02––0.070.17*0.19Age

––0.05–3.03*–3.02–1.74––0.23Education

––0.26––0.24–0.23––0.13Years of schooling

––0.08–0.39––0.55––0.27Marital status

0.210.16–0.08––0.01–0.07Time since diagnosis (months)

––2.41––1.20–2.66–0.60Stage of cancer

–-0.08––2.05–––0.39Subjective socioeconomic status

Caregivers

–––0.55––0.341.73Relationship to patient

––––0.08–––0.11–0.18Contact hours per day

––0.210.21–––0.13–0.20Age

––––0.57––0.672.38Education

–––0.26––0.240.57Years of schooling

–––––––2.03Marital status

Physicians

–0.45–0.36––––0.09––No. of visits

0.04–0.07–0.07–0.05–Overall RSquare

*P< 0.05.

ture studies. In addition, since our study population comprised patients who were referred to the medical on-cology clinic of the Cancer Institute, the results should be generalized with caution.

From our findings it appears that home caregivers can be considered a more authentic source of information for patients’ QoL. Caution should be used in the interpretations of physicians’

reports on patients’ QoL, especially in the cognitive and role functional do-mains. Our findings could be used in the patient decision-making process, research and care planning when pa-tients with breast cancer are unable to self-report.Funding: This study was supported by Tehran University of Medical Sciences.Competing interests: None declared.

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1Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: A.D. Mahmodabadi: Dehghani.arezoo123@gmail.com). 2Academic member of the Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran.3Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.

Received: 09/02/15; accepted: 03/07/16

Messaging standard requirements for electronic health records in Islamic Republic of Iran: a Delphi studyM. Ahmadi 1, S. Foozonkhah 2, L. Shahmoradi 3 and A.D. Mahmodabadi 1

ABSTRACT The present descriptive–comparative study was conducted to give an overview of the messaging standards that are necessary for interoperable electronic health records (EHRs). We designed a preliminary model after data collection and compared the messaging standards of Health Level Seven (HL7) and the International Organization for Standardization (ISO). The data were assessed with the Delphi technique. A comprehensive model for the messaging standards of EHRs in the Islamic Republic of Iran was presented in three pivots: structural characteristics (standard for all EHRs, XML-based and object-oriented messages, and dual model); model specifications (reference model, archetypes and classes of reference model), and general features (distinct ontology, mapping with other standards, and using reference archetypes for exchanging documents). In conclusion, we gave an overview of messaging standards for the interoperability of EHRs and experts selected ISO13606 as a suitable standard for the Islamic Republic of Iran.

املتطلبات القياسية إلرسال الرسائل للسجالت الصحية اإللكرتونية يف مجهورية إيران اإلسالمية: دراسة دلفيمريم أمحدي، شهال فزون خواه، ليال شامهرادي، آرزو دهقاين حممودآبادي

اخلالصــة: أجريــت هــذه الدراســة الوصفية-املقارنــة إلعطــاء ملحــة عامــة عــن معايــر إرســال الرســائل الرضوريــة للســجالت الصحيــة ذات ــا بعــد مجــع البيانــات وقارنــو معايــر إرســال الرســائل مــع "املســتوى الصحــي 7" ومعايــر التشــغيل البينــي، صمــم الباحثــون نموذجــا أوليــة ــص البنيوي ــى اخلصائ ــال ع ــذا املج ــراء يف ه ــد اخل ــد أك ــي. وق ــلوب دلف ــاع أس ــات باتب ــم البيان ــم تقيي ــر". وت ــة للمعاي ــة الدولي "املنظمومواصفــات النمــوذج والســات العامــة ملعايــر إرســال الرســائل. وتــم عــرض نمــوذج شــامل ملعايــر إرســال الرســائل يف الســجالت الصحيــة اإللكرتونيــة يف مجهوريــة إيــران اإلســالمية ضمــن 3 حمــاور: اخلصائــص البنيويــة )معيــار جلميــع الســجالت الصحيــة اإللكرتونيــة، يســتند إىل ــه للمواضيــع، بنمــوذج ثنائــي(؛ ومواصفــات النمــوذج )نمــوذج مرجعــي، وأمثلــة، وأصنــاف ــعة وعــى رســائل ذات توج لغــة التوســيم املوســاط ــرى، واســتخدام أن ــر األخ ــط املشــرتكة مــع املعاي ــيم اخلرائ ــزة، ترس ــة متمي مــن النمــوذج املرجعــي(، والســات العامــة )ســات وجوديمرجعيــة لتبــادل الوثائــق(. ونتيجــة لذلــك، فلقــد قدمنــا ملحــة عامــة عــن معايــر إرســال الرســائل مــن أجــل التشــغيل البينــي يف الســجالت

ــة إيــران اإلســالمية. ــار اخلــراء املقيــاس )ISO13606( ليكــون املقيــاس املالئــم جلمهوري ــة اإللكرتونيــة، وقــد اخت الصحي

Critères des normes de messagerie pour les dossiers de santé électroniques en République islamique d’Iran : une étude selon la méthode de Delphes

RÉSUMÉ La présente étude descriptive comparative a été menée afin de fournir une vue d’ensemble des normes de messagerie nécessaires pour des dossiers de santé électroniques interopérables (DSEi). Nous avons conçu un modèle préliminaire après avoir collecté des données et avons comparé les normes de messagerie de Health Level 7 (HL7) et de l’Organisation internationale de normalisation (ISO). Les données ont été réalisées à l’aide de la technique de Delphes. Un modèle complet pour les normes de messagerie des DSE en République islamique d’Iran a été présenté en trois axes : particularités structurelles (norme pour tous les DSE, messages XML et messages orientés objet, et modèle double) ; spécifications du modèle (modèle de référence, archétypes et classes du modèle de référence) ; et caractéristiques générales (ontologie distincte, correspondance avec d’autres normes, et utilisation d’archétypes de référence pour l’échange de documents). En conclusion, nous avons donné une vue d’ensemble des normes de messagerie pour l’interopérabilité des DSE et les experts ont sélectionné l’ISO13606 comme norme appropriée pour la République islamique d’Iran.

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Introduction

Electronic health records (EHRs) can be processed by computer and stored and exchanged securely by authorized users. Development and use of mes-saging standards for EHRs are needed for information exchange (1–4), and the absence of standards and lack of coordination between systems have made healthcare data sharing difficult (5–8). Lack of standards also hinders the widespread use of EHRs and inte-grated systems in healthcare services in the Islamic Republic of Iran. So, select-ing appropriate standards is a priority for the development of national EHRs (9,10).

Syntactic interoperability guaran-tees exchange of the data structure but does not ensure that the meaning will be interpreted identically by all parties. HTML and XML are good examples of syntactic standards. Semantic interop-erability guarantees that the meaning of a structure is unambiguously exchanged between people (8). Agreement on a standardized set of domain-specific conceptual models and agreement on standardized terminology associated with controlled vocabulary are two ba-sic requisites for semantic interoper-ability. Currently, there are different health informatics standards that define domain models, such as HL7 version 3 Reference Information Model (RIM) and ISO EN 13606 “Health Informatics – EHR communication” (1,11).

Since the 1980s, many countries have tried to implement e-health and then EHRs. This has had a significant influence on the development of EHR standards by the two main interna-tional e-health standard development organizations: HL7 (Health Level 7) and ISO (International Organization for Standardization). HL7 is based in the United States of America and is accredited by the American National Standards Institute (ANSI). HL7 operates in the healthcare field and covers the Americas, some European and Asian countries, and Australia. The

purpose of HL7 is to provide standards for data exchange between different types of healthcare computer applica-tions (12–14). HL7 is formed of health care and information professionals who establish standards for exchange, man-agement and integration of healthcare information (1). HL7 version 3 uses an object-oriented development method-ology and an RIM to create messages; it also uses XML-based messages, a mes-sage development structure with an emphasis on semantic interaction, and interactive models (15–17). In addition to the reference model, HL7 version 3 uses a template to describe specific pat-terns for description and interpretation by humans rather than machines. Four types of models are used in HL7: case, information, interaction and message design models (15,18). Clinical Docu-ment Architecture (CDA) is one of the HL7 standards that has been created for presenting and machine processing of clinical documents (19).

The ISO Technical Committee, ISO/TC 215, is an international stand-ard body that deals with health infor-matics (20). The EN 13606 (Health Informatics – Electronic Health Re-cord Communication) standard is a European norm from the European Committee for Standardization (CEN) that is also approved as an interna-tional ISO standard. It is designed to achieve semantic interoperability for EHR communication and ISO is now responsible for development of the EN 13606 standard. The standard defines architecture for communicating part or all of EHRs. ISO 13606 has two major ontologisms (21,22) and five parts (ref-erence model, archetype interchanges specification, reference archetypes and term lists, security, and interface specifi-cation) (6,16,21,23).

The features of the HL7 and ISO13606 messaging standards are shown in Table 1. The strengths of HL7 version 3 have been investigated in six pivots: interoperability, RIM, simplic-ity, object orientation, dual model and use of XML. Its weaknesses are also

presented in three pivots: structural problems, difficulties in use, and rela-tionship with other standards (1,12,13, 20–24). The strengths of ISO13606 in-clude simplicity, archetype, dual model, reference model, object orientation and linkage or mapping with other terminol-ogy. The lack of relationship between Parts 1–5 is one of the weaknesses of this standard. No more weaknesses have been mentioned in other studies because of the lack of long-term use of the standard (1,22,25,28)

The responsibility for implementing EHRs in the Islamic Republic of Iran lies with the Statistic and Information Technology Office in the Ministry of Health and Medical Education that works on EHR infrastructure, standards and requirements. Furthermore, the Corresponding Technical Committee 215 of ISO has been established in the Ministry. Its mission is the implemen-tation of e-health by preparation of national and international standards in health informatics.

Considering the importance of mes-saging standards for achieving EHRs and the recent decision by the Iran Min-istry of Health and Medical Education to develop EHRs for individuals, this study investigated the EHR messaging standards and proposed an appropriate model for the Islamic Republic of Iran.

Methods

This descriptive–comparative study was conducted in the Islamic Republic of Iran between 2011 and 2012 in the following 3 phases.

Phase I: literature review

We reviewed books, journals, reports and websites and identified HL7 ( h tt p : / / w w w . h l 7 . o r g ) a n d I S O (http://www.ISO.org) as organiza-tions that have messaging standards for EHRs. Other organizations do not have messaging standards specific for EHRs.

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Phase II: model design

After Phase I, to design a preliminary study pattern, we surveyed messaging standards criteria based on three major pivots (structural features, model speci-fication and general features).

Phase III: testing questionnaire reliability and validity of proposed model

To design the proposed model, we used the Delphi technique. A questionnaire was designed. For each item in every pivot, three options were considered: I agree, I disagree, and no idea. Pivot priority was considered in model speci-fication. To assess the validity of the questionnaire, it was administered to several academic professionals, medical record specialists and health informa-tion administrator. After 10 days, the same individuals were asked to com-plete the questionnaire for a second

time. The data collection method was approved by the specialists.

After testing the reliability, the ques-tionnaires were sent to 37 specialists, including university staff in health infor-mation management departments and experts in the EHR domain of the Min-istry of Health and Medical Education who were familiar with EHR standards. The questionnaires were either sent by e-mail or delivered in person, and reminders were sent after a few days. Thirty-three participants completed the questionnaires. The questionnaires were received within 7 weeks and the data were collected and analysed.

We applied descriptive statistical methods for data analysis. For the first part of the questionnaire, the items in the model that were approved by < 50% of experts were excluded and those approved by ≥ 75% of the experts were adopted. The items approved by 50–74% of the experts and their

recommended items based on other options were identified. These items were assessed in the second stage of the Delphi technique to achieve a consen-sus. In the second stage, questionnaires were sent to the same 37 experts, and 29 completed the questionnaires. The second part of the questionnaire related to the standard models and the ques-tions were designed based on their pri-ority. The frequency was calculated for each priority and then the means of the priorities were calculated. Calculated priorities ranged from 1 to 3, and in some cases from 1 to 6. The scores were multiplied by the response frequency and divided by the number of respond-ents. When analysing the results, the smaller the percentage, the greater the priority and vice versa. The final model design was based on the means of the priorities.

Table 1 Features of HL7 and ISO 13606 messaging standards

HL7ISO13606General features of messaging standards of HERDefines rigorous and stable information architecture

for communicating part or all of the HERMission

Standards for the exchange, management, and integration of healthcare information

ModelsIncluded parts

–Archetype

–Template

Information modelAvailable model

–Use case model, interaction model, message design model

Reference modelCore model

–Act, roll, participation, entities, act relationship, roll link

Classes of reference model

HER – extract, folder, composition, section, entry, element, cluster, record component, audit-information, function role, attestation-information, link

–Message development framework and hierarchical message description

Development plan

–OntologyaOther criteria

Dual model

–Architecture for documentation exchange

Term lists

–Mapping with other standards

XMLExchange language

aOntology is the structural frameworks for information that is transferred by means of systems, therefore, inevitably messaging standards use it. HER = electronic health record.

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Results

In the Delphi phases, about 56.5% and 43.5% of the specialists were women and men, respectively, and 52.2% were aged 25–34 years and the rest 35–54 years. About 43.5% of the participants had 3–9 years of work experience and 56.5% had > 10 years. For academic achievement, 17.4% had a master’s de-gree, 4.3% had a bachelor’s degree and 78.3% had a PhD. The field of study was health information management in 82.6% of the participants and health informatics and software engineering in 13%. A total of 65.2% were faculty members while about 34.8% were not.

According to the specialists’ views about appropriate messaging standards for EHRs, standards for exchange, man-agement and integration of healthcare data were necessary. In other words, messaging standards were deemed necessary for all areas of health care. Reference models were most important for the essential and main parts of the messaging standards for EHRs. The emphasis was on the reference model and interactive model of EHRs. The use of terminology such as SNOMED (Systematized Nomenclature of Medi-cine), LOINC (Logical Observation Identifiers), and ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revi-sion), is considered suitable for the on-tology of the EHRs (Table 2).

The experts’ emphasis on structural featur e s required for EHRs was based

on XML - based and object-oriented messages (Table 3).

To select an appropriate model for messag i ng standards and designing its cl a sses, essential subclasses of each class were expressed and the priority of each one was determined by the experts (Table 4).

Discussion

A major healthcare challenge is to create interoperability between EHR systems that can be achieved with the selection of app r opriate standards (10). Some compar a tive studies have shown that some o r ganizations have a messaging standa r d like HL7 for the exchange, management and integration of health-care i n formation and ISO13606 de-fines r igorous and stable information archi t ecture for communicating part or al l of the EHRs of a single recipient of ca r e (20, 25). The proposed model of Ir a nian experts emphasized the use of st a ndards for exchange of data and information in all areas of health care.

Atala g et al. (1) and Jaffe (29) deter m ined the structural features of stand a rds for EHRs that included the use of RIM, messages based on XML, message development framework with an em p hasis on interoperability, ob-ject orientation, interaction model, and displ a ying complex relationships. The Irani a n experts also had an emphasis on XM L -based and object-oriented messages. Although other studies have empha s ized the information models,

the experts in our study placed this fea-ture as the second priority.

Wolle r sheim et al. have suggested that, to present the clinical documen-tatio n components, each messaging standard uses a number of models and the types of model in the 2 standards are different and based on different objec-tives (27). Among the existing models, expe r ts emphasize the reference and inte r action models. Wollersheim et al. have reported that the reference model provides a base for data definition and incl u des several classes that support medi c olegal requirements and record management functions (27). The mod-el m a kes it possible to access further requ i rements of EHRs, which leads to the e xchange of information between discrete systems.

Resu l ts of previous studies have revealed that ontology is used to share and r euse specific domains. As ontol-ogy is the structural framework for the tran s fer of information by systems, its use by messaging standards is inevitable (20, 26, 30). The Iranian experts em-phas i zed the use of terminology such as S N OMED, LOINC and ICD10 for ontology. SNOMED and LOINC are not commonly used in the Islamic Republic of Iran; therefore, the experts emphasized the use of ICD10 for death and disease coding.

Several studies have indicated that the H L7 orga n ization uses the neces-sary termino l ogy when it exists in a spec i fic are a ; otherwise, the technical committee will create it. With regard to

Table 2 Experts’ opinion of the scope, essential and main parts, essential models, and ontology of EHR messaging standards

Percentage General feature

56.5For all health domainsScope of standard

76.2Reference modelsEssential and main parts

53.0Archetype

71.4Information modelEssential models

52.4Use case model

81.0Interaction model

85.7Use of current terminologies likeSNOMED and LOINC

Ontology

EHR = electron health record; LOINC = Logical Observation Identifiers; SNOMED = Systematized Nomenclature of Medicine.

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Table 3 Experts’ opinion of the structural features of EHR messaging standards

Percentage Structural features

76.2Use of reference information model

85.7Message based on XML

61.9Message development framework with emphasis on interoperability

85.7Object oriented

Table 4 Experts’ opinion of essential subclasses for act, participation, entity, role, composition, section, entry, cluster, function role, and authentication in EHRs

Mean of priority Essential subclassesEssential EHR classes2.3ObservationEssential subclasses for act

class 1.8Procedures (medication or surgery)

3Supply

3.4Financial action

3.3Management

1.5PerformerEssential subclasses for participation class 2.6Author

1.6Subject

1.4Physician, nurse, other care staff and non-care staffEssential subclasses for entity class 2Hospital or other healthcare organizations

2.3Material and care devices

2.6PatientEssential subclasses for role class 1.6Attending physician or surgeon

2.1Nurse

3.2Paraclinical staff

4.2Financial staff

1.1Clinical report, e.g., documentation of patient progress Essential subclasses for composition class 1.7Paraclinical report such as laboratory results

2.9Health assessment

1.1Reason of encounterEssential subclasses for section class 2.8Past history, family history

3Allergy information

2.7Laboratory result

2Clinical signs, e.g., vital signs Essential subclasses for entry class 2.5Observation, test results

2.7Prescribed drugs

2.4Differential diagnosis

2Test results, e.g., electroencephalogramEssential subclasses for cluster class 1.8Weighted differential diagnoses

2Drug prescription organized as a time series

1.2Function that was performed in the situationEssential subclasses for function role class 1.9Identity of the agent performing the function

2.6The mode in which participation was made (e.g., in person, by telephone)

2.5The type of service location, department

2.1The date and time at which attestation occurredEssential subclasses for attestation information class 1.3The person who made this attestation

EHR = electronic health record.

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using ontology, the ISO13606 stand-ard tries to maintain coordination with common terminology. In the context of ISO13606 standards, plans have been devised for homogenization with other standards such as HL7 and openEHR (6). A research by Karla has suggested that different standards have to be matched with each other to meet the broad need for healthcare (31), which was confirmed by the current study.

Our results also indicate that the 2 standards have specific methods for the exchange of clinical documents. HL7 uses a CDA standard and ISO13606 uses reference archetypes (1,6,20). Ira-nian experts put emphasis on reference archetype for the exchange of clinical documents.

The proposed model is presented in three main pivots of EHR messag-ing standards: structural characteristics (standards for all EHRs, XML-based and object-oriented messages, and dual

model), model specifications (refer-ence model, archetypes, and classes of reference model), and general features (separate ontology, mapping with other standards, and using reference arche-types for exchanging documents).

Other countries like Turkey, Egypt, Saudi Arabia, South Africa and Malaysia emphasize XML, reference models and interaction models as requirements for messaging standards. Previous studies – Other countries like Turkey, Egypt, Saudi Arabia, South Africa and Malaysia emphasize XML, reference models and interaction models as requirements for messaging standards. Previous studies have also mentioned the use of special standards for exchanging documents (32–35).EHRs and their standards are impor-tant in the Islamic Republic of Iran; therefore, more research in this field must be conducted. According to the results of the current study and research

experience, ISO 13606 is suitable for the situation in the Islamic Republic of Iran. Also, having a committee corre-sponding to ISO/TC 215 in the Iranian Ministry of Health and Medical Educa-tion provides an opportunity for better cooperation with ISO.Considering the approach of the Min-istry of Health and Medical Education towards the creation of an EHR for each Iranian, and the absence of customized messaging standards in the healthcare system, we recommend using the pro-posed model in an attempt to meet the requirements for messaging standards in the Islamic Republic of Iran (Figure 1).Funding: This study was part of a MS Dissertation supported by Tehran Uni-versity of Medical Sciences. Competing interests: None de-clared.

Final model for messaging standards of Iran EHR

Structural features

General features

Model specifications

standard for all electronic health records

dual model

xml and object-oriented based message

separate ontology

mapping with other standards

using reference archetypes for exchanging documents

reference model

classes of reference model

archetypes

composition class

section class

entry class

cluster class

function_role class

Figure 1 Proposed model for requirements for messaging standards in the Islamic Republic of Iran.

EHR = electronic health record

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1Department of Prevention and Community Dentistry; 2Department of Periodontology, Faculty of Dentistry, University of Khartoum, Khartoum, Sudan (Correspondence to: H.M. El-Mahdi Ibrahim: hindmahdi@yahoo.com).

Received: 22/08/14; accepted: 26/07/16

Oral health status, knowledge and practice among pregnant women attending Omdurman maternity hospital, SudanH.M. El-Mahdi Ibrahim 1, A.M. Mudawi 1 and I.A. Ghandour 2

ABSTRACT Good oral health is important in pregnancy but little is known about the oral health and knowledge and practices of pregnant Sudanese women. This cross-sectional study was conducted to address this gap. A sample of 420 pregnant women attending the prenatal clinic at Omdurman maternity hospital were interviewed and examined for caries and periodontal disease. The mean age of the women was 27.1 (SD 5.8) years, 52.4% had > primary school education and 7.1% were employed. Only 12% had a high level of oral health knowledge and 21.2% a positive attitude towards oral health. Most of the women (65.9%) had poor oral health practices; only 10.2% had visited a dentist during pregnancy. On clinical examination, 58.6% had healthy gums while 12.1% had bleeding gums and 22.9% had calculus. The mean decayed, missing and filled teeth value was 1.16 in the age group 16−19 years and 3.49 in age group ≥ 20 years. These findings suggest the need for oral health programmes as part of prenatal care for pregnant Sudanese women.

حالة صحة الفم واملعلومات واملامرسات لدى إحدى احلوامل السودانيات املراجعني ملستشفى الوالدة يف أم درمانهند حممد املهدي إبراهيم، أمل حممد مضوي، إبراهيم عبد العزيز غندور

اخلالصــة: لصحــة الفــم أمهيتهــا يف احلمــل، إال أن املعلومــات قليلــة حوهلــا وحــول مــا يتعلــق هبــا مــن املعلومــات واملامرســات لــدى احلوامــل الســودانيات. ــة الســابقة للــوالدة يف مستشــفى ــادة الرعاي ــة ملــلء هــذه الفجــوة. وشــملت الدراســة 420 حامــا ممــن يراجعــن عي ولقــد أجريــت هــذه الدراســة املقطعيالــوالدة يف أم درمــان، حيــث متــت مقابلتهــن وفحصهــن لتحــري تســوس األســنان ومــرض دواعــم األســنان. ولقــد كان متوســط العمــر ألولئــك احلوامــل ــط ــن فق ــح أن %12 منه ــن. واتض ــن يعمل ــام كان %7.1 منه ــم، ك ــة يف التعلي ــة االبتدائي ــن املرحل ــاوز %52.4 منه ــاري 5.8(، وجت ــراف املعي ــا )االنح 27.1 عام

لدهيــن مســتوى رفيــع مــن املعلومــات حــول صحــة الفــم، وكان لــدى %21.1 منهــن مواقــف إجيابيــة جتــاه صحــة الفــم. وكان لــدى الثلثــن تقريبــا )65.9%( ممارســات ســيئة ذات عاقــة بصحــة الفــم، ومل يقــم أكثــر مــن %10.2 منهــن بزيــارة طبيــب األســنان أثنــاء احلمــل. وبالفحــص الرسيــري اتضــح أن 58.6% ــس. وكانــت القيمــة املتوســطة لعــدد األســنان املنخــورة أو ــدى %22.9 منهــن تكل ــة، ول ــة نازف ــدى %12.1 منهــن لث ــام كان ل ــة ســليمة، بين منهــن لدهيــن لثــة 20 عامــا أو أكثــر. وتشــر هــذه النتائــج إىل احلاجــة لربامــج ــة 19 – 26 عامــا، و 3.49 يف املجموعــة العمري املفقــودة أو املحشــوة 1.16 يف املجموعــة العمري

صحــة الفــم كجــزء مــن الرعايــة الســابقة للــوالدة التــي تقــدم للحوامــل يف الســودان.

État de santé bucco-dentaire, connaissances et pratiques en la matière parmi des femmes enceintes à la maternité de l’hôpital d’Omdourman (Soudan)

RÉSUMÉ Une bonne santé bucco-dentaire est importante en période de grossesse, mais peu d’informations sont disponibles sur l’état de santé bucco-dentaire, les connaissances et les pratiques des femmes enceintes soudanaises en la matière. La présente étude transversale a été conduite afin de combler cette lacune. Un échantillon de 420 femmes enceintes de la clinique prénatale de la maternité de l’hôpital d’Omdourman ont été interrogées et examinées afin de déterminer si elles souffraient de caries et de parodontopathies. L’âge moyen des femmes étaient de 27,1 ans (ET 5,8) ; 52,4 % avaient suivi un enseignement primaire, et 7,1 % avaient un emploi. Seulement 12 % d’entre elles avaient une bonne connaissance de la santé bucco-dentaire, et 21,2 % démontraient une attitude positive en la matière. La majorité des femmes (65,9 %) avaient de mauvaises pratiques d’hygiène bucco-dentaire, et seulement 20 % s’étaient rendues chez un dentiste au cours de leur grossesse. À l’examen clinique, 58,6 % avaient des gencives saines, contre 12,1 % qui souffraient de saignements gingivaux et 22,9 % qui avaient du tartre dentaire. La moyenne de l’indice CAO (dent cariée, absente ou obturée) était de 1,16 pour le groupe d’âge des 16–19 ans, et de 3,49 pour le groupe d’âge des 20 ans et plus. Ces résultats laissent penser qu’il existe un besoin en programmes de santé bucco-dentaire dans le cadre des soins prénatals pour les femmes enceintes soudanaises.

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Introduction

Pregnancy is a natural process character-ized by physiological changes, including fluctuating hormones. These changes increase susceptibility to oral infections such as pregnancy gingivitis, peri-odontitis and oral pyogenic granuloma (1−4). Periodontal disease has been reported to be associated with other health problems such as cardiovascular disease, diabetes, low birth weight and preterm birth (5−7). In addition, cer-tain cultural beliefs may impede proper nutrition and the ability of pregnant women to achieve good oral health (8). Unfortunately, it is widely observed that many women with obvious signs of oral disease do not visit a dentist before, during or after pregnancy (9). Some, fear that they or their fetus might be harmed by dental treatment, others consider poor oral health status during pregnancy as normal (10). Appropriate knowledge, attitude and behaviour of pregnant women could prevent oral problems and their complications dur-ing pregnancy (11).

A woman’s knowledge of and action on her own oral health are important for the oral health of her children (12). Children whose mothers have poor oral health are 5 times more likely to have oral health problems than children whose mothers have good oral health (13). Mothers are the main source of transmissible cariogenic bacteria to their children; it has been shown that Streptococcus mutans of mother and child are phenotypically and genotypically similar (14).

Pregnant women are readily ac-cessible as most of them have regular antenatal check-ups. Furthermore, their key position in the family enables them to have a great influence over the behav-iour of family members and they play a very important role in educating the young generation (15). Thus, educating pregnant women on oral health can be an effective way of conveying dental health education to the general public,

starting at the individual level, then to the family and finally to the community level (16).

Pregnant women in Sudan generally have limited access to oral health educa-tion and no previous study in Sudan has assessed the oral health status, and knowledge, attitude and dental practic-es of pregnant women. The aim of this study therefore was to assess the oral health status, knowledge, attitude and practices among a sample of pregnant Sudanese women in order to obtain the base-line data needed to establish an oral health preventive programme during pregnancy.

Methods

Study design and settingThis was an observational, cross-sec-tional, hospital-based study conducted among pregnant women attending the prenatal outpatient clinic in Omdur-man Maternity Hospital. This hospital was selected because it is the largest gov-ernment maternity hospital in Sudan and a considerable number of pregnant women of different socioeconomic levels attend daily for examination and regular prenatal care. It has 12 wards for delivery (248 beds) and 5 delivery rooms (25 beds) with about 65 deliver-ies per day. In addition the hospital has an outpatient clinic and prenatal care with approximately 350 visits a day from pregnant women.

Sample size and selectionThe minimum sample size was com-puted using the formula n = z2pq/d2, where n = required sample size; z = 1.96 at 95% confidence interval; p = antici-pated prevalence of women with good oral health knowledge (set at 50%); q = 1 − p; d is the desired precision (set at 0.05). Thus, the computed minimum sample size was 384 women. This was increased to account for attrition.

All patients available in the clinic when the researcher was present were

approached and informed verbally about the study. The women were in-formed that non-participation would not affect their care. Those who agreed to participate were included in the study after signing a written informed consent form. Illiterate women had the form read to them and marked the form if they consented to participate. Those agreeing to participate were interviewed about their medical history and those who were suffering from any mental or physical disease were excluded.

After refusals and ineligibility to participate were excluded, 420 preg-nant women from the prenatal clinic of Omdurman maternity hospital were enrolled in the study over a period of 8 weeks to reach the required sample size (June−July 2010).

Data collection

The research is composed of two parts; face-to-face interview and clinical ex-amination.

Face-to-face interviewAll the participants were interviewed by the first author and a questionnaire (of 32 questions) was completed. The questionnaire was adapted by the research team from standard question-naires used in other studies (16−18). It was translated into Arabic by postgradu-ate students (Division of Preventive and Community Dentistry, University of Khartoum) and back translated into English by the staff of the Division of Preventive and Community Dentistry, University of Khartoum. This criterion validation step was supported by the research team’s expertise and collective judgement on the final refined version of the questionnaire. To assess reliability, the questionnaire was pilot-tested on a group of 35 women. This pilot process revealed the optimal time for question-naire completion by participants, while the statistical analysis revealed a good agreement with kappa statistics result ranging from 0.75% to 100%.

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The questionnaire had 5 parts: 1) Sociodemographic data (age, national-ity, educational level, occupation, num-ber of current pregnancy, average of family income, medical insurance); 2) Perceived oral health (current and last dental pain, gum problem); 3) Dental practice (tooth-brushing, other oral hy-giene methods, dental visit before and during pregnancy); 4) Attitude before and during pregnancy (dental care be-haviour during pregnancy, behaviour towards dental pain during pregnancy); 5) Knowledge about the cause of tooth decay, gum disease and how they can be prevented, and the source of knowledge.

The Registrar General’s classifica-tion of social classes groups for the United Kingdom (UK) was used in this study as it is widely used in medi-cal research (19). This system of clas-sification is based on occupation. It groups occupations into social classes according to their skill level and gen-eral social standing in the community. Unemployed women are allocated on the basis of their husband’s occupation

(19).After completing the interview, the

knowledge, attitude and practice ques-tions were evaluated and scored. For knowledge, the scoring system was: high knowledge = a score of 13−17, av-erage knowledge = 7−12, and low = 0−6. For attitude, the scoring system was: positive attitude = a score of 6−12 and negative attitude = 0−5 score. Finally, for practices: good practices = a score of 19−27, average = 10−18, and bad = 0−9. The relationships between these 3 main variables were examined.

Clinical examinationThe second part of the research was the clinical examination which was performed by the first author. A full mouth examination was done for all the women who finished the interview us-ing the Community Periodontal Index (CPI) and decayed, missed and filled teeth (DMFT) according to World Health Organization (WHO) criteria

(20). For CPI the highest score of the clinical examination was taken for every subject. The DMFT were modified from the WHO descriptions based on age (21). The clinical status scores were compared with scores of knowledge, attitude and practice.

After examination, 5 women were randomly selected each day and asked to return before they left so as to be re-interviewed and re-examined for test−re-test purposes.

Data analysisSTATA software, version 8 was used for statistical analysis. Descriptive statistics were used for data classification; the chi-squared test was used to evaluate the differences between different categori-cal variables (knowledge and attitude; knowledge and practice; knowledge and oral health status; attitude and oral health status; and practice and oral health status). Statistical significance was set at P < 0.05.

Ethical clearanceEthical approval for the study protocol was obtained from the Research Board, Faculty of Dentistry, University of Khartoum. An approval letter was also obtained from the Academic Depart-ment of the hospital to conduct the research and every patient participating in the study signed a written informed consent form. Code numbers were used instead of names to ensure anonymity and confidentiality.

Results

Sociodemographic backgroundThe response rate was 89% (48 women declined to participate and 4 were ineligible according to our exclusion criteria). Table 1 shows the sociode-mographic characteristics of the 420 pregnant women who were eligible and agreed to participate in this study. The age range of the participants was

16−44 years with a mean and standard deviation (SD) of 27.1 (SD 5.8) years. Of the 420 participants, 10.7% were il-literate, 36.9% had up to primary-school education, 30.2% had high-school edu-cation and 22.2% had higher education. The majority of the women (92.9%) were housewives and only 13.6% had medical insurance. According to the Registrar General’s classification of so-cial classes (19), the largest proportion were from intermediate class II (27.4%) based on their husband’s occupation. For 30.5% of the women, this was their first pregnancy.

Perceived oral healthAlmost a quarter of the 420 women (22.6%) felt that their current oral health was poor, 45% felt it was average, 18.6% good, 5.5% very good and 8.3% excellent. At the time of the interview, 151 (36%) of the women felt dental pain and 82 (19.5%) were found to have gingival/periodontal problems.

Oral health knowledgeWith regard to oral health knowledge scores among the pregnant women, 82% had an average score indicating medium level of knowledge, 12% high scores and 6% low.

Table 2 shows the oral health knowl-edge of the participants. The majority of the women (88.1%) agreed that tooth-brushing prevents tooth decay, gum diseases and a bad smell. Only 2.6% thought that brushing is just a habit. Most of the women (69.5%) believed that the main cause of tooth decay was sugar and 31.9% thought that the cause was bacteria. Just over half (52.4%) of the women thought that tooth decay could be prevented by tooth cleaning and brushing, while 22.1% thought it could be prevented by avoidance of sweets and sugar. A majority of the women (58.3%) thought that the cause of gum disease was unclean teeth and food debris and 71.7% thought that gum disease could be prevented by tooth

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cleaning and brushing while 17.9% did not know.

The main sources of oral health knowledge were: television (cited by 59.0% of the women), radio (51.9%), family (49.0%) and the dentist (42.4%).

Oral health attitudeWith regard to oral health attitude among the pregnant women, 21% had a positive attitude, i.e. expressing a willing-ness to take care of their oral health and to change towards a better oral health care and showing an openness to new practices, ideas and concepts.

Only 20.0% of the sample planned to visit a dentist and 26.2% said that pregnancy affected their attitude to-wards oral health. Of these 110 women, 20.0% considered this change as bad, 23.6% as average, 33.6% as good, 13.6% as very good and 9.1% as excellent. About 89% of the 26.2% whose attitude had changed, changed their behaviour by brushing their teeth more frequently, 2% by visiting the dentist for a check-up and by 3% visiting the dentist when they felt pain; the other 6% exhibited other changes such as using mouth wash, de-creasing sugar intake and drinking milk. However, 73.8% did not change their attitude during pregnancy.

Oral health practicesEvaluation of oral health practices among the pregnant women showed that 66% had bad oral practices and 34% average oral health practices; none of the women had good oral health preactices

Table 3 shows the oral health prac-tices of the participants. The majority of the women (85.5%) reported that they brushed their teeth more than once a day, while 14.5% brushed once a day. Only 9.5% used other oral hy-giene methods such as dental floss, tooth pick, miswak and mouth wash. A small majority (58.1%) of the women reported that they had visited a dentist before pregnancy; their main reason was dental pain (84%). A large propor-tion of the women (42%) had never

visited a dentist in their life. Only 10.2% of the pregnant women had visited a dentist during pregnancy; the main reason for the visit was toothache. Of the 377 women who had not visited the dentist during pregnancy, 62.1% did not do so because they did not think that they needed dental care, and 27.9%

thought that they and their baby might be harmed by dental treatment.

Relationships between sociodemographic characteristics, knowledge, attitude and practice

The chi-squared test showed that there was a significant relationship between the age and attitude to oral health (P =

Table 1 Sociodemographic characteristics of the sample of Sudanese pregnant women (n = 420)

Variable No. %Age (years)

16–20 57 13.6

21–26 153 36.4

27–32 131 31.2

33–44 79 18.8

Mean (SD) 27.14 (5.832)

Educational level

Illiterate 45 10.7

Primary school 155 36.9

High school 127 30.2

University 88 21.0

Postgraduate 5 1.2

Current job

Housewife 390 92.9

Employed 30 7.1

Social classa

Professional 22 5.2

Intermediate 115 27.4

Skilled non-manual 41 9.8

Skilled manual 63 15

Semi-skilled manual 90 21.4

Unskilled general 89 21.2

Medical insurance

Yes 57 13.6

No 363 86.4

Monthly family income (Sudanese pounds)

Minimum 200 (US$ 70)

Maximum 30 000 (US$ 1000)

Mean (SD) 1240.86 (1810.85)

Current pregnancy

1st 128 30.5

2nd 86 20.5

3rd 56 13.3

4th 49 11.7

≥ 5th 101 24aBased on husband’s occupation. SD = standard deviation.

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0.045) and age and oral health practice (P = 0.044). There was also a significant relationship between education and oral health knowledge (P = 0.001) and education and oral health prac-tice (P = 0.003). Similarly, a significant

relationship was found between current pregnancy and oral health practice (P = 0.003) (Table 4).

Pearson correlation indicated that there was no relationship between oral health knowledge and practice (P =

0.8962), oral health knowledge and attitude (P = 0.6393), and between oral health attitude and practice (P = 0.1729).

Clinical examinationsThe clinical examination indicated that 246 (58.6%) of the study sample had healthy gum, 51 (12.1%) had bleeding, 96 (22.9%) had calculus, 8 (1.9%) had pockets and 19 (4.5%) were excluded (the index tooth was not found, e.g. it was unerupted or extracted).

Only 24.5% of the women were free from dental caries. The mean DMFT was 1.16 in the age group 16−19 years and 3.49 in age group ≥ 20 years.

The chi-squared test indicated that there was no statistically significant re-lationship between CPI and oral health knowledge (P = 0.712) and CPI and oral health attitude (P = 0.203), but there was a statistically significant rela-tionship between CPI and oral health practice (P = 0.003) (Table 5).

The chi-square test showed that there was no statistically significant relationship between DMFT and oral health knowledge (P = 0.249), and DMFT and oral health attitude (P = 0.065); however there was a statistically significant relationship between DMFT and oral health practice (P < 0.001) (Table 5).

Discussion

Our study showed that the major-ity of our sample of pregnant Sudanese women (81.9%) had average oral health knowledge, but they were unaware of the relationship between oral health and pregnancy. Similarly, in Iowa, United States of America (USA) Hubashna et al. 2005 showed that women had lim-ited knowledge of the possible relation-ship between oral health and pregnancy outcome (18). In addition, it has been reported that women are not aware that the health of their gums may also affect the health of their babies (6). It has

Table 2 Oral health knowledge among a sample of Sudanese pregnant women (n = 420)

Variable No. %

Advantages of tooth brushing

Prevents bad smell 370 88.1

Prevents tooth decay 356 84.8

Prevents gum disease 305 72.6

Only habit 11 2.6

Causes of tooth decay

Sugar and carbohydrate consumption 292 69.5

Bacteria 134 31.9

Other 49 11.7

Methods to prevent tooth decay

Tooth cleaning and brushing 220 52.4

Avoidance of sweets and sugar 93 22.1

Tooth brushing and mouth wash after meals and sweets 57 13.6

Tooth-brushing and regular check ups 4 1.0

I don’t know 43 10.2

Other 3 0.7

Causes of gum disease

Food debris and unclean teeth 245 58.3

Bacteria 158 37.6

I don't know 52 12.4

Other 13 3.1

Methods to prevent gum disease

Tooth cleaning and brushing 301 71.7

Tooth-brushing and mouth wash after meals 9 2.1

Tooth cleaning and regular check ups 15 3.6

Mouth wash 12 2.9

I don’t know 75 17.9

Other 8 1.9

Source of knowledge

Television 248 59.0

Radio 218 51.9

Family 206 49.0

Dentist 178 42.4

Magazine 158 37.6

Outdoor advertising (e.g. billboards) 144 34.3

My experience 54 12.9

School curriculum 24 5.7

From my study 1 0.2

Women could select more than one answer for each variable.

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been shown that periodontal disease increases the risk of adverse pregnancy consequences (18).

Women in our study mainly ac-quired their oral health knowledge from

television and radio. These media may be useful and suitable for the dissemina-tion of oral health education messages in Sudan. This was in contrast to a study conducted in the UK where the main

source of knowledge of mothers who were aware of dental care was the gen-eral practitioner (19) while in Kuwait, 65% of female students at a health sci-ence centre reported that they received tooth-brushing instructions from the dentist (22).

Most of our sample (78.8%), which had different age groups, educational levels and social classes, had a negative attitude to oral health during pregnancy. About 90% did not visit a dentist; of those, more than half did not feel they needed to, and a considerable propor-tion thought that dental treatment should be avoided during pregnancy as it might harm their baby or themselves. Likewise, a survey in the USA revealed that half of the women who reported oral problems did not seek care because they believed that poor oral health dur-ing pregnancy was routine and feared that dental treatment might harm their baby (10).

The majority of the studied sample had good tooth-brushing habits (brush-ing more than once a day), but only about 10% used adjunct oral hygiene methods. However, in a study in the UK, only 75% of the pregnant women brushed their teeth more than once a day and 51% used mouth wash (19). Likewise, in Australia the dental uti-lization rate of pregnant women was only about 30% (23). Also in a study in Kuwait a large proportion of the preg-nant women had oral health problems; however, half of the women had not seen a dentist during pregnancy (22).

In our study, there was a statistically significant relationship between wom-en’s educational level and oral health knowledge. Higher educated women had greater oral health knowledge than lower educated or uneducated women. While education increased knowledge, surprisingly, no statistically significant relationship was found between oral health knowledge and attitude, and also between oral health knowledge and practice. This may be due to fear, cultural factors and wrong beliefs. In

Table 3 Oral health practice among a sample of Sudanese pregnant women (n = 420)

Variable No. %

Tooth-brushing

More than once/day 359 85.5

Once/day 61 14.5

Other oral hygiene method

None 380 90.5

Dental floss 6 1.4

Tooth picks 5 1.2

Mouth wash 7 1.7

Miswak 21 5.0

Other 1 0.2

Dentist visit before pregnancy

Yes 244 58.1

No 176 41.9

Reasons for visit before pregnancy (n = 244)

Check-up 5 2.0

Scaling 13 5.3

Toothache 205 84.0

Gum problem 20 8.2

Filling 14 5.7

Prosthesis 5 2.0

Last visit (n = 244)

< 6 months ago 7 2.9

6– 74 30.3

1– 81 33.2

> 2 years ago 82 33.6

Dentist visits during pregnancy

Yes 43 10.2

No 377 89.8

Reasons for visit during pregnancy (n = 43)

Check-up 2 4.7

Scaling 3 7.0

Toothache 37 86

Filling 1 2.3

Reasons for not visit dentist during pregnancy (n = 377)

Afraid of the dentist 2 0.5

No need 234 62.1

My baby or myself may be harmed 105 27.9

No time 27 7.2

Financial reasons 8 2.1

No dentist in my vicinity 1 0.3

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contrast, in the Islamic Republic of Iran in 2008, Hajikazemi et al. found a statis-tically significant relationship between oral health knowledge and attitude, and knowledge and practice (11).

The clinical examination results indicated that over a third (36.9%) of the women in the present study had gum problems while only about a fifth complained of gum problems. This result suggests that about 15% of the women had gum problems but did not recognise it. Furthermore, of the women complaining of gum problems, only 15% had visited a dentist. The Cali-fornia Dental Association recommends that all women who are pregnant or planning a pregnancy visit a dentist for a periodontal examination and maintain good oral hygiene during pregnancy (24).

A large proportion of the women in our study experienced dental caries (75%), but fortunately only 2.2% had high caries levels. However, only 5% of the affected population had fillings, indicating that almost 95% had no den-tal treatment for some reason. Studies

reveal that dentists are sometimes reluc-tant to treat pregnant women for vari-ous reasons, such as the fear of harming the fetus, fear of litigation or patient safety concern (14,25).

We found a statistically significant relationship between oral health status and oral health practice, i.e. between CPI and practice, and DMFT and prac-tice. That oral health is affected by oral practice is to be expected, i.e. the better the practice, the better the oral health. Vasiliauskien et al. in 2007 found that a preventive programme in Lithuania among pregnant women led to a 56% reduction in the dental caries increment of the study group in comparison with the control group (26). The oral hy-giene index also decreased from 1.48 to 0.94 in the study group indicating an improvement in periodontal status (26).

This is the first study conducted in Sudan assessing oral health status, knowledge, attitude and behaviour among pregnant women. Although most pregnant women in Khartoum state receive a comprehensive form

of antenatal care from maternity care centres, they do not receive instruc-tions concerning oral health care dur-ing pregnancy. A pregnant woman’s knowledge and actions concerning her oral health are critical to the oral health of her children and play a vital role in childhood caries prevention (27), and some countries have adopted a strat-egy of maternal oral health promotion through antenatal care providers (28).

Our study showed that the oral health status of the pregnant women was at a middling level but that the ma-jority had negative attitudes towards oral health and had poor oral health practice. Oral health knowledge therefore needs to be enhanced and oral health preven-tive programmes should be developed for pregnant women. These would en-courage good oral practice and a posi-tive attitude toward oral health and lead to better oral health status. Pregnant women should be a priority group for oral health education and this should be an integral part of antenatal or postnatal care programmes.

This study was conducted among a sample of pregnant women from one maternity hospital. As such the sample cannot be considered to be representa-tive of all pregnant women in Sudan and the results cannot be generalized to a wider population. Nonetheless, our study points to the need for preventive programmes, including oral health edu-cation during prenatal care, to increase awareness of oral health among preg-nant women and improve oral health practice.

Acknowledgements

We are grateful to all the pregnant women who participated in this study.Funding: None.Competing interests: None declared.

Table 4 Association between sociodemographic characteristics of the pregnant women and their oral health knowledge, attitude and practice

Variable P-value

Knowledge Attitude Practice

Age 0.762 0.045* 0.044*

Education 0.001* 0.590 0.003*

Social class 0.775 0.904 0.242

Current job 0.094 0.398 0.182

Current pregnancy 0.732 0.642 0.003*

*Statistically significant at P < 0.05.

Table 5 Association between oral clinical examination and oral health knowledge, attitude and practice of the pregnant women

Variable P-value

Knowledge Attitude Practice

CPI 0.712 0.203 0.003*

DMFT 0.249 0.065 0.000*

*P-value statistically significant at P < 0.05. CPI = community periodontal index; DMFT = decayed, missed and filled teeth.

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27. Boggess KA, Urlaub DM, Moos MK, Polinkovsky M, El-Khorazaty J, Lorenz C. Knowledge and beliefs regarding oral health among pregnant women. J Am Dent Assoc. 2011 Nov;142(11):1275–82. PMID:22041414

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1Department of Community Medicine, Isra University, Hyderabad, Pakistan (Correspondence to: J. A. Soomro: jamiljan197@hotmail.com). 2Department of Community Medicine, Dow University of Health Sciences, Karachi, Pakistan. 3Department of Nursing and Health Promotion, Oslo and Akershus University College, Oslo, Norway.

Received: 07/07/15; accepted: 02/08/16

Factors affecting breastfeeding practices among working women in PakistanJ.A. Soomro 1, Z.N. Shaikh 2, S.A. Bijarani 1 and T.B. Saheer 3

ABSTRACT In urban areas of Pakistan, women's return to work after giving birth has frequently been found to be a main contributor to the early termination of breastfeeding. This study aimed to assess workplace breastfeeding support provided to working mothers in Pakistan. In a cross-sectional survey in 2014, mothers and employers from a representative sample of 297 workplaces were interviewed using a pre-tested questionnaire. Mothers from 36 (12.1%) sites reported receiving breastfeeding breaks, and 86% of the mothers had received 3 months paid maternity leave. Provision of a lighter job and information about breastfeeding options on return to work were reported from 15% and 5% of the workplaces, respectively. Only two sites had designated breastfeeding corners. Significantly different results were found between types of employer (government or private) and type of organization (national or multinational) with regard to breastfeeding breaks, breastfeeding corners, lighter jobs and paid maternity leave. Public and multinational companies were slightly better than private and national ones in providing breastfeeding facilities.

العوامل التي تؤثر عىل ممارسات الرضاعة الطبيعية بني العامالت يف باكستانمجيل أمحد سومرو، ذيشان نور شيخ، سهيل أمحد بجاراين، تينيجيدارا بخاري شهري

اخلالصــة: اتضــح أن عــودة العامــات إىل عملهــن بعــد والدهتــن يف املناطــق احلرضيــة يف باكســتان كثــريا مــا تكــون املســاهم الرئيــي يف إهنــاء الرضاعــة الطبيعيــة. وهتــدف هــذه الدراســة إىل تقييــم الدعــم الــذي يقدمــه مــكان العمــل يف باكســتان لألمهــات العامــات يف جمــال الرضاعــة الطبيعيــة. ومــن خــال دراســة مقطعيــة أجريــت عــام 2014 لعينــة مــن األمهــات العامــات وأربــاب العمــل يف 297 مكانــا للعمــل تــم إجــراء مقابــات باســتخدام اســتبيان مســبق االختبــار. وقــد أبلغــت األمهــات مــن 36 موقعــا )%12.1( عــن تلقيهــن إجــازات للرضاعــة الطبيعيــة، كــا تلقــى %86 مــن األمهــات إجــازات أمومــة مدفوعــة األجــر ملــدة 3 شــهور. وقــد تــم اإلبــاغ عــن تقديــم مــكان العمــل ألعــال أخــف من الســابق يف %15 مــن احلــاالت وتقديــم مــكان العمــل ملعلومــات حــول االختيــارات املتاحــة للرضاعــة الطبيعيــة عنــد العــودة إىل العمــل يف %5 مــن احلاالت. ولقــد خصــص موقعــان فقــط مــن أماكــن العمــل ركــن للرضاعــة الطبيعيــة. وقــد تــم احلصــول عــى نتائــج خمتلفــة اختافــا واســعا بــن أنــواع أربــاب العمــل )حكوميــن أو مــن القطــاع اخلــاص( ونــوع املنظمــة )وطنيــة أو دوليــة( يف مــا يتعلــق بإجــازات الرضاعــة الطبيعيــة، وختصيــص ركــن لــه، واألعــال األخــف مــن األعــال يف الفــرة الســابقة لإلرضــاع، وإجــازة األمومــة املدفوعــة األجــر. ولوحــظ أن رشكات القطــاع العــام أو

املتعــددة اجلنســيات أفضــل قليــا مــن الــركات الوطنيــة والقطــاع اخلــاص يف تقديــم التســهيات اخلاصــة بالرضاعــة الطبيعيــة.

Facteurs affectant les pratiques d’allaitement parmi les femmes actives au Pakistan

RÉSUMÉ Dans les zones urbaines du Pakistan, le retour des femmes au travail après un accouchement contribue très souvent à l’arrêt précoce de l’allaitement. La présente étude avait pour objectif d’évaluer les conditions favorables à l’allaitement au travail pour les mères actives au Pakistan. Au cours d’une étude transversale réalisée en 2014, des mères et des employeurs issus d’un échantillon représentatif de 297 lieux de travail ont été interrogés sur la base d’une questionnaire préalablement testé. Les mères travaillant sur 36 lieux de travail (12,1 %) ont rapporté que des pauses étaient aménagées pour qu’elles puissent allaiter, et 86 % des mères ont bénéficié d’un congé maternité payé de 3 mois. La possibilité d’un travail allégé et la mise à disposition d’informations sur les options existantes pour l’allaitement après un retour au travail étaient rapportées dans 15 % et 5 % des lieux de travail respectivement. Seuls deux lieux de travail disposaient d’un espace dédié à l’allaitement. Des résultats significativement différents ont été obtenus selon les types d’employeurs (gouvernement ou privé) et d'organisations (nationales ou multinationales) concernant les pauses aménagées pour l’allaitement, les espaces mis à disposition à cette fin, un travail allégé et les congés maternités payés. Les entreprises publiques et multinationales se sont révélées légèrement meilleures que les entreprises privées et nationales dans la mise à disposition d’un environnement propice à l’allaitement.

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Introduction

Breastfeeding is an important measure in safeguarding children’s health and survival (1). In Pakistan it is estimated that 78 out of every 1000 live-born children die before their first birthday (2). According to the United Nations Children’s Fund (UNICEF), 16% of infant deaths could be prevented by breastfeeding from birth (2). From 1983 to 2008, the percentage of women in Pakistan who breastfed for up to one year declined from 96% to 31% (3). Workplace barriers have been reported as one of the major reasons for early cessation of breastfeeding by working mothers (3–6). Returning to work has frequently been found to be a main contributor to the early termi-nation of breastfeeding (7,8). Many mothers who return to work stop or reduce breastfeeding because they do not have enough time or an appropri-ate place to breastfeed or express and store their breast milk (7–9). Studies indicate that mothers who have easy access to their baby during the working day, or who can express breast milk at work, breastfeed their babies for longer than those who do not have such access (9,10). A supportive environment, such as paid maternity leave, part-time work engagements, facilities for expressing and storing breast milk at work, breast-feeding breaks and national legislation on breastfeeding support at work have resulted in a higher prevalence and longer duration of breastfeeding (7,10).

For employers, the benefits of providing a working environment fa-vourable to breastfeeding outweigh the costs. If breastfeeding is supported in the workplace, women are more likely to return to work earlier after giving birth, which contributes to women pre-serving their job skills, as well as reduc-ing staff turnover (11–13). A survey in Hong Kong Special Administrative Region of China showed that 26% of workplaces had allocated a separate room for breastfeeding, and only 11%

of hospitals allowed employees to take breaks as needed to use a breast pump (14).

Several studies have reported the importance of national legislation in supporting breastfeeding practices at work (10,13,14). One study noted that “policies can validate the employees’ right to provide their milk for their chil-dren, even when individual supervisors or co-workers are less than supportive’’ (14). In Pakistan, the lack of legisla-tion (other than that providing for three months’ paid maternity leave) in sup-port of working mothers breastfeeding at work may be a contributing factor to the non-adherence of employers to international guidelines (3).

A qualitative study in Pakistan reported workplace barriers as one of the main reasons for early cessation of breastfeeding among working mothers (15). However, there has been little research into workplace breastfeeding facilities. The current study examines the status of the available breastfeed-ing facilities in Pakistan with a view to obtaining insights that could be useful to decision-makers.

Methods

Study design and samplingA cross-sectional survey was conducted in 2014 on 297 workplaces, randomly selected from 2983 registered sites in Karachi, Pakistan. Karachi has a popula-tion of around 23.5 million, making it the largest city of Pakistan (16). The population of the city includes almost every socioeconomic class and ethnic group living in Pakistan. Additionally, it is home to Pakistan's major business activities and a hub of higher education (16). All workplace sites registered with appropriate government authorities, i.e. hospitals, banks, factories and schools, were considered as the relevant study population (17–20).

At each selected site, one employer and one mother were interviewed. The employer was a manager or officer rep-resenting the workplace unit. Mothers were included if they were 3–24 months postpartum, had initiated breastfeeding prior to the survey, and at the time of the interview had returned to the job they had before giving birth. The mothers were selected purposively.

It was assumed that some employ-ers in the randomly selected sample (n = 296) would refuse to take part in the study. Therefore, 7% extra workplaces were included in the initial sample. A fi-nal sample of 297 sites was achieved; ten sites were found not to be eligible, while eight employers refused to participate in the study. Female research assistants were trained to invite participants for the interview, to conduct the interview and to complete the questionnaire. The participants were given a sheet that contained information about the sur-vey and contact details of the principal investigator. The research assistants were trained to explain the nature of the research, why the participant had been chosen, and her or his right to refuse to participate or to withdraw from the survey at any time.

The study was approved by the in-stitutional review board of the Dow University of Health Sciences, Pakistan, and the South-Eastern Regional Ethical Committee of Oslo, Norway.

Data collectionThe structured questionnaire was de-signed in English and Urdu based on guidelines of the World Alliance for Breastfeeding (21). The questionnaire was pretested in eight workplace sites, with equal representation of public and private enterprises. Subsequently, some changes were made to the survey’s language and style to improve its com-prehensibility.

The questionnaire comprised two sections. The first section enquired about sociodemographic characteris-tics of the workplace: site level (national

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versus multinational), job site (bank, school, hospital or factory) and type of employer (government, private, self-employed). Because the study focused on assessing workplace breastfeeding facilities, identifying information for the workplace, such as the name and ad-dress of the site, and personal details of the employer and the mother were not collected to avoid potential ethical issues,.

The second section enquired about breastfeeding facilities, such as whether there were breastfeeding breaks, a breastfeeding corner, a place to store breast milk, a crèche or nursery at the workplace, paid maternity leave, pos-sibility of moving to a lighter job, and options to facilitate breastfeeding (part-time work, extension of maternity leave or change of shift). Responses were yes or no. Mothers and employers were considered the persons in a workplace most likely to know about the avail-ability of breastfeeding facilities. The employers and mothers from each site were interviewed using the same ques-tionnaire, to enhance the confidence of the quality of our findings.

Statistical analysis

The data were analysed on Stata version 13 and SPSS version 22. All the variables were categorical. Descriptive statistics were computed by running frequencies and cross-tabulations on SPSS to obtain percentages and confidence intervals. Differences were considered statisti-cally significant when P < 0.05. Charts were also developed using graph and chart builder.

Stata version 13 was used to com-pare proportions. Differences in pro-portions of breastfeeding facilities, with 95% confidence intervals (CI), were ex-amined by type of respondent (mother or employer) type of employer (govern-ment or private) and site level (national or multinational). For the comparison by type of employer and site level, we used the mothers’ responses.

Results

A total of 594 participants from 297 sites completed the questionnaire. Table 1 shows the characteristics of the sample. The largest groups in the sample were banks (42%), private employers (75%)

and national-level sites (76%). Figure 1 shows the availability of breastfeed-ing facilities at work according to the mothers (n = 297). Paid maternity leave was provided in most of the workplaces (86%). Only 15% of the sites provided mothers with a lighter or safer job while they were lactating. It was observed that most of the job assignments for female employees were fixed, with the excep-tion of banks and schools; no other site had the possibility to relocate mothers to a site closer to their home to make breastfeeding easier. In 12% of the sites, at least one hour of paid breastfeeding breaks was offered during a work shift of 6–8 hours. Only two workplaces had a crèche on site providing child care and had designated a breastfeeding corner; none of the sites had a designated facil-ity for storage of breast milk for later use.

The same questionnaire was used with the mothers and the employers, so that responses from the two different groups could be compared (Table 2). Altogether, 96% of the employers claimed that the mothers were provided breastfeeding breaks, compared with 12% of the mothers. The difference in

86%

15%

12% 5%

0.70% 0.70% 0.70% 0%

0102030405060708090

100

%

Paid matern

ity le

ave

Lighter job pro

vision

Breastfeeding breaks

Breastfeeding optio

ns

Breast milk

pump

Jobsit

e Crèche (n

ursery)

Breastfeeding corn

ers

Refrigrato

r for b

reast milk

storage

Figure 1 Provision of workplace breastfeeding facilities, according to mothers

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proportions between employers and mothers was statistically significant. Similarly, employers overestimated non-physical breastfeeding facilities compared with mothers, such as paid maternity leave (100% vs 86%), avail-ability of lighter jobs (45% vs 15%), and provision of breastfeeding options for mothers on their return to work, e.g. part-time work, extension of ma-ternity leave, or change of shift (21% vs 5%). However, no significant difference was observed between the two groups in their responses regarding physical breastfeeding facilities, such as a breast milk pump, jobsite crèche for child care, and availability of a place for storing breast milk (refrigerator).

The status of breastfeeding facilities in the public and private sectors was compared, using the responses of the mothers only. More public workplaces than private ones were reported to pro-vide at least three months paid mater-nity leave (99% vs 81%). This difference was statistically significant (P < 0.001). Similarly, breastfeeding breaks of at least one hour in a shift of 6–8 hours were also more common in the public sector (23% vs 9%) (P < 0.001). Only the mothers in the private sector (7%) reported having breastfeeding options

for their return to work (part-time work, change in shift, maternity leave extension). A breastfeeding corner was provided by 1% of the government sites and none of the private sites. However, this difference was not statistically sig-nificant. No workplace had a designated place or refrigerator to store mothers’ milk. A breast milk pump and jobsite crèche or nursery for child care was provided by 1.3% of the government facilities and 0.5% of the private compa-nies; the difference was not statistically significant.

Table 3 shows the difference in proportions of workplace breastfeed-ing facilities between multinational and national sites. The multinational sites provided more breastfeeding facilities than the national sites and the difference was statistically significant (P < 0.001). The facilities included: breastfeeding breaks of at least one hour per shift (25% vs 8%); at least three months paid maternity leave (100% vs 81%); provi-sion of lighter job or transfer to a safer workplace during lactation (38% vs 8%); provision of appropriate options to support breastfeeding at work (17% vs 2%). Most of the multinational sites offered more than three months paid leave. Surprisingly, none of the facilities

had allocated a place, such as a refrigera-tor, for working mothers to store breast milk for their babies.

Discussion

To the best of our knowledge, this is the first quantitative study in Pakistan exclusively focusing on assessment of workplace breastfeeding facilities with a large random sample. Information was obtained from two sources, mothers and their employers, using the same type of questionnaire in order to in-crease confidence in the findings. Our study revealed that the workplaces gen-erally had few breastfeeding facilities. The two groups of respondents gave significantly different answers regarding non-physical facilities, such as breast-feeding breaks, maternity leave, avail-ability of a lighter job, and provision of information about breastfeeding op-tions. Breastfeeding support was slightly better in public and multinational sites than in private and national sites.

Mothers in 12% of the workplaces reported that they had breaks to breast-feed or express breast milk. This was similar to the findings of Dodgson et al. (11%) (14) and Weber et al. (16%) (22). Heymann et al. (23) found that, globally, the rate of exclusive breastfeed-ing of children under six months of age was 9% greater in countries that ensured paid breastfeeding breaks at workplaces. A qualitative study in Pakistan by Hirani et al. (15) also found that job flexibility and a flexible schedule at the workplace were important if working mothers were to sustain breastfeeding while em-ployed.

However, our findings with regard to breastfeeding breaks are not consist-ent with those of many studies in devel-oped countries, possibly because of the existence in those countries of work-place breastfeeding policies, lactation programmes and additional support to mothers in the form of education

Table 1 General characteristics of the sample

Characteristic Number Percentage

Total 297 100

Type of business

Bank 123 42

School 87 29

Factory 66 22

Hospital 21 7

Interviewees

Mother 297 50

Employer 297 50

Type of employer

Private 222 75

Government 75 25

Site level

National 226 76

Multinational 71 24

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On the other hand, mothers may have under-reported breastfeeding facilities in order to obtain additional benefits or to attract the attention of de-cision-makers. Mothers may have little awareness of workplace breastfeeding rights set by labour organizations (lo-cal and international). Finally, in large workplaces, mothers may not be aware of all the available facilities, especially the less visible ones (separate rooms, separate refrigerators, etc.).

However, the two groups of re-spondents showed general agreement on the availability of the following breastfeeding facilities: a breastfeed-ing corner, a refrigerator, a breast milk pump and a nursery. This agreement may be because all these were physi-cal facilities and could be verified. The mothers are probably the more reliable group, because of their direct interest and benefit from breastfeeding facilities.

The significant difference observed between private and public sector organizations, with regard to breast-feeding breaks, maternity leave, task adjustment and information regarding breastfeeding options, is consistent with the findings of other studies (14,23,29). In Pakistan, mothers working in the public sector tend to have greater workplace breastfeeding support than those in the private sector, because of the nature of the work. The majority of banks, factories, and companies with a rigid type of job and short rest periods

and resources (24–28). The availability of breastfeeding corners, a breast milk pump and a place for storing breast milk (refrigerator) would allow women to feel more confident and encourage them to breastfeed (3,29).

In our study, only two sites had a designated breastfeeding corner and workplace crèche for child care. These findings are similar to those of some previous studies (14,29), but different from the studies by Allen et al. (25) and Bai et al. (27), which reported 70% and 80%, respectively. The large differ-ence is most likely the result of policies, programmes and awareness-raising of women by lactation consultants in those study settings, all of which are lacking in Pakistan.

Almost 86% of the mothers were given paid maternity leave for three months in our study, similar to what was found in studies in Malaysia and India (93%) (29,30). However, the paid maternity leave cannot be compared with many other studies in countries such as Australia, Canada, China and the Islamic Republic of Iran, which offer more than three months paid or unpaid maternity leave (9,23,31,32).

The finding that women in only 5% of the sites reported receiving informa-tion about breastfeeding options on their return to work is consistent with that of Weber et al. (5%) (23). The lack of policies and lactation programmes in Pakistan limits the relevance of

comparison of the findings with other studies (25,27,28).

Little literature is available for comparison of the perspectives of the employer or owner on workplace breastfeeding facilities. A qualitative study in Pakistan concluded that the employer’s perspective is critical for understanding and supporting breast-feeding in workplaces (15). Tan et al. reported that the employer’s behaviour influences working mothers’ percep-tion of workplace breastfeeding support (33).

Employers tended to overestimate the available workplace breastfeeding facilities, possibly for fear of harming the reputation of the organization or of negatively affecting their status if the data were shared with the government. Employers may think that providing facilities for breastfeeding mothers could be financially damaging for the workplace, or that breastfeeding is a per-sonal activity that reduces the time em-ployees spend working. The employers may have thought that the data would be communicated to international or nongovernmental organizations, which might then put pressure on the govern-ment to take action against sites without facilities. Finally, breastfeeding facilities may be confused with other staff facili-ties (routine breaks over breastfeeding breaks, female common room as a breastfeeding room, etc.) (3,33,34).

Table 2 Comparison of responses of mothers and employers regarding breastfeeding facilities provided in workplaces

Workplace breastfeeding facilities Mothers responding yes

Employers responding yes

Test of difference in proportion

(95% Cl)

P value

No. % No. %

Breastfeeding breaks 36 12 285 96 84 (80–88) <0.001

Breastfeeding corners 2 0.7 17 6 5 (2–7) <0.001

Breast milk pump 2 0.7 3 1 0.03 (0.01–0.081) 0.653

Jobsite crèche for child care 2 0.7 5 1.7 0.01 (-0.02–0.07) 0.254

Paid maternity leave 255 86 297 100 14 (10–18) <0.001

Lighter job or task adjustment 45 15 134 45 30 (23–37) <0.001

Breastfeeding options (part-time work, etc.) 16 5 63 21 16 (11–21) <0.001

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Nevertheless, the study setting (Ka-rachi) is the largest city of Pakistan and the second-largest city in the world by population size, and includes almost every social class and ethnic group liv-ing in Pakistan (16). We believe the results could be generalized to the other cities in the country, since it is likely that working mothers have similar working conditions, tasks, culture, and socio-economic status. Our study could also serve as a baseline in specific settings, for follow-up studies to examine the impact of interventions, such as policy reform and workplace lactation programmes. Our findings could also inform future large population-based surveys in urban and rural areas, to get a clear picture of breastfeeding facilities at workplaces in Pakistan.

Acknowledgements

The authors thank Professor Per Naf-stad, Department of Community Medi-cine, University of Oslo for his technical support throughout the study period.Funding: The authors acknowledge the research committee at the Section for International Health, University of Oslo, Oslo, Norway for funding the study.Competing interests: None declared.

are privately owned, in contrast to jobs in schools and hospitals in the govern-ment sector, which tend to be less busy. Moreover, the public sector is more likely to adopt breastfeeding-friendly policies (14,23,29).

A significant difference was also seen between the national and multinational sectors, in the provision of breastfeed-ing breaks, separate rooms, maternity leave, task adjustment and information. There has been no previous study com-paring breastfeeding support in national and multinational sites. The difference in our study could be related to the fact that most of the multinational compa-nies in Pakistan have their headquarters in high-income countries that have breastfeeding policies, and this influ-ences the employer to support working mothers (3,23,31,35). Another reason could be the greater adherence to inter-national labour laws by multinational companies than national companies in developing countries (21,31,32). Meet-ing the needs of breastfeeding workers is best achieved when there is a clear-cut policy to address these issues. Without such a policy, these issues and the need to make changes within an organization are not brought to the attention of the employer (21,32).

There is a need for national legisla-tion to address these problems. Without national laws or regulations, employ-ers are not legally obliged to provide the necessary facilities at the workplace for encouraging mothers to breastfeed their infants. This legislation could be based on the WHO International Code of Marketing of Breast-Milk Substitutes (36), which aims to promote breast-feeding and enhance infants’ health.

We recognize that our study had several limitations. First, it focused only on an urban area of Pakistan; the re-sults, therefore, cannot be generalized to rural areas, which account for one-third of female workers (16). Secondly, unregistered workplaces, such as shops, small clinics and home-based busi-nesses, were not included. Though such workplaces are small in number, they may influence the internal and external validity of our study. Thirdly, our sample was dominated by private sector com-panies, mainly banks and schools, and this may also have influenced our results through under-representation of the public sector and sites such as hospitals and factories. Finally, the mothers were enrolled purposively because of limited time and resources, which could have influenced the results.

Table 3 Comparison of breastfeeding facilities provided in national and multinational sites, according to mothers

Workplace breastfeeding facilities Multinational(n = 71)

National(n = 226)

Test of difference in proportion (95% Cl)

P value

No. % No. %

Breastfeeding breaks 18 25 18 8 17 (7–28) < 0.001

Breastfeeding corners 2 3 0 0 3 (1–6) < 0.001

Breast milk pump 0 0 2 1 0 .08 (0.3–2) 0.426

Jobsite crèche for child care 0 0 2 1 0.08 (0.3–2) 0.426

Paid maternity leave 71 100 184 81 19 (14–24) < 0.001

Lighter job or task adjustment 27 38 18 8 30 (18–42) < 0.001

Breastfeeding options (part-time work, etc.) 12 17 4 2 15 (6–24) <0.001

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26. Dixit A, Feldman-Winter L, Szucs KA. “Frustrated”, “depressed” and “devastated” pediatric trainees: US academic medical centers fail to provide adequate workplace breastfeeding sup-port. J Hum Lact. 2015; 31:240-8.

27. Bai YK, Gaits SI, Wunderlich SM. Workplace lactation support by New Jersey employers following US Reasonable Break Time for Nursing Mothers law. J Hum Lact. 2015;31(1):76–80.

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29. Amin RM, Said ZM, Sutan R, Shah SA, Darus A, Shamsuddin K. Work related determinants of breastfeeding discontinua-tion among employed mothers in Malaysia. Int Breastfeed J. 2011;6(1):4.

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31. Atabay E, Moreno G, Nandi A, Kranz G, Vincent I, Assi TM et al. Facilitating working mothers’ ability to breastfeed: global trends in guaranteeing breastfeeding breaks at work, 1995-2014. J Hum Lact. 2015;31(1):81–8.

32. International Labour Organization. Maternity at work: A review of national legislation. Findings from ILO database of condi-tions of work and employment laws. Geneva: International Labour Office; 2012 (www.ilo.org/global/standards/lang--en/index.htm, accessed February 2014).

33. Chow T, Smithey Fulmer I, Olson BH. Perspectives of managers toward workplace breastfeeding support in the state of Michi-gan. J Hum Lact. 2011;27(2):138–46.

34. Hirani SA, Karmaliani R. Breastfeeding support for working mothers: Global and Pakistani perspectives. Curr Pediatr Rev. 2012;8(4):313–21.

35. Ip S, Chung M, Raman G, Chew P, Magula N, Devine D et al. Breastfeeding and maternal and infant health outcomes in de-veloped countries. Evid rep technol assess. 2007; (153):1–186.

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1College of Medicine, King Abdul Aziz University, Jeddah, Saudi Arabia. 2King Saud bin AbdulAziz University for Health Sciences, King Abdullah International Medical Research Center, Infection Prevention and Control, King AbdulAziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia. 3Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt. (Correspondence to: F.M. Farahat: farahatfa@ngha.med.sa)

Received: 31/10/15; accepted: 03/08/16

Psychobehavioural responses to the 2014 Middle East respiratory syndrome-novel corona virus (MERS CoV) among adults in two shopping malls in Jeddah, western Saudi ArabiaN.S. AlNajjar, 1 L.M. Attar, 1 F.M. Farahat 2,3 and A. AlThaqafi 2

ABSTRACT Sporadic cases of Middle East respiratory syndrome caused by a novel corona virus (MERS-CoV) were first detected in Saudi Arabia in June 2012. The number of cases was highest during April and May 2014. To assess determinants of psychobehavioural responses among the general population in Jeddah, western Saudi Arabia, a cross-sectional survey was conducted at the end of June 2014. Data included sociodemographic characteristics, level of anxiety, protective measures and social avoidance responses. A total of 358 participants completed the questionnaire; 58.4% were female, and the age range was 18–72 years. None of the participants was diagnosed with MERS-CoV. More than half (57.7%) recorded a moderate anxiety score using a visual analogue scale. Anxiety level was significantly associated with increased perception of susceptibility to infection and social avoidance behaviours related to travel and being in public places.

ــن يف ــدى البالغ ــية )2014( ل ــط التنفس ــرق األوس ــة ال ــبب ملتالزم ــد املس ــا اجلدي ــروس كورون ــلوكية لف ــية الس ــتجابة النفس االســعودية ــة الس ــة العربي ــرب اململك ــدة، غ ــوق يف ج ــن للتس جممع

نرسين سعيد النجار، جلني مدحت عطار، فيصل مصطفى فرحات، عبد احلكيم عقاب الثقفي

اخلالصــة: تــم اكتشــاف متالزمــة الــرق األوســط التنفســية التــي يســببها فــروس كورونــا أوال يف اململكــة العربيــة الســعودية يف يونيو/حزيــران 2012.ولقــد دات االســتجابة النفســية والســلوكية بــني عامــة الســكان يف جــدة، بلــغ عــدد احلــاالت أعــى مســتوى لــه خــالل شــهر أبريل/نيســان 2014. ولتقييــم حمــدــة ــات اخلصائــص االجتامعي ــران 2014. وتضمنــت املعطي ــة شــهر يونيو/حزي ــذ مســح مقطعــي يف هناي ــم تنفي ــة الســعودية، ت الواقعــة غــرب اململكــة العربيوالســكانية، ومســتوى القلــق، والتدابــر املتخــذة للوقايــة، واالســتجابة بالتجنــب االجتامعــي. ولقــد اســتكمل االســتبيان 358 مشــاركا يف الدراســة، وكان %58.4 منهــم مــن النســاء، وكانــت األعــامر تــراوح بــني 18 و 72 عامــا. ومل يســبق ألحــد مــن املشــاركني أن شــخص لديــه اإلصابــة بفــروس كورونــا اجلديــد املســبب ملتالزمــة الــرق األوســط التنفســية. ولقــد ســجل أكثــر مــن نصــف املشــاركني )%57.7( درجــة معتدلــة مــن القلــق باســتخدام مقيــاس القيــاس البــري املضاهــئ. وقــد ترافــق مســتوى القلــق مــع زيــادة ذات أمهيــة إلدراك قابليــة التعــرض للعــدوى ولســلوكيات اجتامعيــة للتجنــب تتعلــق بالســفر

وباحلضــور يف األماكــن العامــة.

Réactions psycho-comportementales à l’infection par le coronavirus du syndrome respiratoire du Moyen-Orient (MERS-CoV) de 2014 chez des adultes interrogés dans deux centres commerciaux de Djeddah, dans l’ouest de l’Arabie saoudite

RÉSUMÉ Des cas sporadiques d’infection par le coronavirus du syndrome respiratoire du Moyen-Orient (MERS-CoV) ont été détectés pour la première fois en Arabie saoudite en juin 2012. Le nombre de cas le plus élevé a été observé en avril et mai 2014. Afin de mesurer les déterminants des réactions psycho-comportementales de la population générale de Djeddah, dans la partie occidentale de l’Arabie saoudite, une étude transversale a été conduite fin juin 2014. Les données incluaient les caractéristiques socio-démographiques, le niveau d’anxiété, les mesures de protection et la mise en place de mesures d’éviction sociale. Un total de 358 participants ont rempli le questionnaire, dont 58,4 % de femmes, les âges étant compris entre 18 et 72 ans. Le MERS-CoV n’a été diagnostiqué chez aucun patient. Plus de la moitié (57,7 %) a rapporté un score d’anxiété modéré en se basant sur une échelle visuelle analogue. Le niveau d’anxiété était associé de façon significative à une perception augmentée de sensibilité à l’infection et au phénomène d’éviction sociale lié à la possibilité de voyager ou de se rendre dans les lieux publics.

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Introduction

A Middle East respiratory syndrome caused by a novel corona virus (MERS-CoV) was first detected in Saudi Arabia in June 2012. The number of cases in-creased to a peak in April and May 2014 (1,2). The total number of reported cases up to June 2014 was 714, with a case fatality rate of 40.8% (1). Another peak occurred in 2015, however, with fewer cases (440 to end of December 2015) (1).

Most patients with MERS-CoV infection were severely ill with pneu-monia and acute respiratory distress syndrome, and some had acute kidney injury (3). Up to June 2014 the mode of transmission was uncertain but was thought to be through direct (droplet) or indirect (touching contaminated surfaces) contact (4).

Unconfirmed beliefs about modes of transmission and doubts regarding the adequacy of national preparedness influence public compliance with pre-cautionary measures and have been associated with avoidance behaviours and increased psychological distress (5,6). Avoidance behaviours and anxi-ety symptoms were experienced during the human avian influenza outbreaks and the SARS epidemic (7–9). During the 2009 H1N1 pandemic, anxiety was associated with high perceived suscep-tibility to infection and disease severity that influenced hygiene measures (5) or led to social distancing, rather than substantial changes in hygiene behav-iour (10).

People are more compliant if they believe they may be affected by the outbreak (11,12), the recommended behaviours are effective (13), the illness has severe consequences (14) or is dif-ficult to treat (15) and there is sufficient information on controlling the spread of infection (16).

Knowledge of psychobehavioural responses among the general public during epidemics could determine risk

communication and public health inter-ventions (10,17).

A study conducted on healthcare workers in a tertiary care hospital in Jed-dah during the 2014 MERS CoV out-break reported emotional distress and reluctance to work overtime in despite their feelings of ethical and professional obligation towards their profession (18). During the 2014 emergence of MERS-CoV, other generally observed public responses (e.g. avoiding crowded places and hospitals, wearing face masks in mosques and public areas and chang-ing travel plans) have not yet been ex-plored.

Accordingly, our study aims to ad-dress psychobehavioural responses in terms of psychological distress/anxiety and avoidance behaviours associated with MERS CoV occurrence among the Saudi population in Jeddah, west-ern Saudi Arabia, where the majority of cases were reported during the 2014 outbreak.

Methods

We carried out a cross-sectional study in June 2014 in 2 shopping centres in Jeddah, western Saudi Arabia. These centres were selected by a simple ran-dom sampling technique from a list of 12 large shopping malls which people visit for shopping, recreation and to meet friends.

Study participants were selected us-ing a convenience sampling technique among people who were sitting in the open dining areas from 17.00–22.00 hours during the study period (16–26 June 2014). Study participants included male and female adult (> 18 years) Saudi Arabian and non-Saudi Arabian people residents of Jeddah during the 2014 MERS-CoV outbreak.

Verbal consent was obtained from each participant to voluntarily par-ticipate in the study. The purpose of the study, procedures, risks, benefits and alternatives to participation were

explained to each potential participant. Each potential participant was afforded sufficient time to ask questions and con-sider whether or not to participate in the study and complete the questionnaire.

Data were collected through a self-administered questionnaire developed based on similar previous studies conducted in China and Hong Kong during the H7N9 and H1N1 epidemics (10,19). The questionnaire included data on sociodemographic characteristics of the participants, avoid-ance responses, use of protective meas-ures, perceptions and overall knowledge about the 2014 MERS-CoV outbreak. Knowledge was assessed through 7 questions on mode of transmission, clinical features, severity, prevention and availability of a vaccine. One point was given for every correct response and zero for an incorrect response. Those who scored ≥ 4 out of 7 (> 50% correct) were considered as having average/high knowledge.

The questionnaire was pretested for face and content validity, length and comprehensibility. Face validity was es-tablished by expert opinion. The pretest was conducted on 10 volunteer partici-pants (5 male and 5 female) randomly selected from the same location. After pretesting, no changes were required. A 5-point Likert response scale was ap-plied and the average time for comple-tion was about 10 minutes.

A 10 cm horizontal line visual ana-logue scale (VAS) was used to assess level of anxiety among the study popula-tion (20–21). At the left edge zero = not at all anxious, and at the right edge 10 = extreme anxiety. Each participant marked the point on the line that they felt represented their level of anxiety towards the MERS CoV infection. The distance from the left edge to the mark was measured to the nearest mm and used in analyses as the participant anxi-ety score (21,22). The VAS is a valid, reliable, simple to administer tool that has been used successfully for assessing a variety of health outcomes including

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pain (23), quality of life (24), mood (25) and anxiety (21,22).

All questionnaires were anonymous. Approval of the Institutional Research Board of King Abdullah International Medical Research Center was obtained to conduct the study.

Sample size was estimated assuming 25% prevalence of anxiety related to the

emergence of MERS CoV in Jeddah based on a similar study by Rubin et al. during the swine influenza outbreak (26). At 95% confidence interval, 5% margin of error, 285 was estimated as the sample size. This was increased to 400 to compensate for incomplete questionnaires or non-response.

Statistical analysis

Data were analysed using SPSS, version 21. The Mann–Whitney and Kruskal–Wallis tests were applied to compare anxiety scores in different groups. Asso-ciations between independent variables and anxiety were assessed using univari-ate and multivariate logistic regression analysis, with calculation of odds ratios

Table 1 Regression analysis of independent variables associated with anxiety among a sample of adults in Jeddah, 2014, n = 358

Variablea Anxiety VAS ≥ 5No. (%)

Anxiety VAS < 5No. (%)

Unadjusted OR (95% CI)

Adjusted OR (95% CI)

Sex

Male 77 (52.4) 70 (47.6) 1 1

Female 129 (61.4) 81 (38.6) 1.45 (0.95–2.22) 1.14 (0.65–2.01)

Age

≤ 30 years 102 (55.4) 82 (44.6) 1 1

> 30 years 67 (63.2) 39 (36.8) 1.38 (0.85–2.26) 1.21 (0.62–2.35)

Nationality

Saudi Arabian 146 (56.4) 113 (43.6) 1 1

Non-Saudi Arabian 42 (60.9) 27 (39.1) 1.20 (0.70–2.07) 1.55 (0.71–3.40)

Marital status

Single 79 (51.6) 74 (48.4) 1 1

Married 127 (62.6) 76 (37.4) 1.57 (1.02–2.40) 1.67 (0.98–2.85)

Education

Less than university 47 (54.7) 39 (45.3) 1 1

University 155 (58.9) 108 (41.1) 1.19 (0.73–1.95) 1.14 (0.98–1.33)

Incomeb

Enough 178 (58.0) 129 (42.0) 1 1

Not enough 28 (56.0) 22 (44.0) 0.92 (0.51–1.69) 1.03 (0.40–2.66)

Perception of personal health status

Satisfied 143 (53.8) 123 (46.2) 1 1

Not satisfied 63 (68.5) 29 (31.5) 1.87 (1.13–3.09) 2.49 (1.31–4.75)

Know of MERS CoV positive case

No 158 (56.8) 120 (43.2) 1 1

Yes 45 (61.6) 28 (38.4) 1.22 (0.72–2.07) 1.03 (0.52–2.04)

Percieved probability of being infected with MERS CoV

Unlikely 99 (47.4) 110 (52.6) 1 1

Likely/very likely 105 (73.4) 38 (26.6) 3.07 (1.94–4.86) 3.25 (1.86–5.70)

Overall knowledge on MERS CoV

Not enough 66 (56.4) 51 (43.6) 1 1

Enough 137 (591) 95 (40.9) 1.11 (0.71–1.75) 1.15 (0.64–2.06)

CI = confidence interval. OR = odds ratio VAS = visual analogue scale (5 is the median score of the study sample); aData missing for some variables. bSelf-reported income: enough = being able to cover monthly expenses.

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and 95% confidence intervals. Anxiety score was used as a binary variable (≥ 5 vs < 5) in the regression analysis. Only those variables which were statistically significant in the crude analysis were introduced in the final model. Statistical significance was set at P < 0.05.

Results

A total of 400 participants of about 420 approached agreed to complete the questionnaire. Questionnaires that were returned blank or with the major-ity of the questions unanswered, includ-ing those which were not marked on the anxiety VAS, were excluded: a total of 358 questionnaires were analysed. Demographic characteristics can be seen on Table 1. More than half of the participants were female (210, 58.7%). Age ranged between 18 and 72 years. The majority of the participants were Saudi Arabian (259, 72.3%). About

three-quarters reported feeling satisfied about their general health condition.

None of the participants had been diagnosed with MERS-CoV. Around one-fifth of them (73, 20.4%) knew of a confirmed case of MERS-CoV (Table 1), of whom 87.7% (n = 64) had been admitted at hospital and 74.0% (n = 54) had died. When asked about the prob-ability of being infected with MERS CoV, 58.6% perceived the probability of infecton as unlikely compared with 27.2% who percieved it as likely and 13.8% as very likely (Table 1).

More than half the participants (57.7%) reported anxiety level score of ≥ 5 (study sample median) on a 10 cm VAS [mean anxiety score 4.94, standard deviation (SD) 2.29].

Univariate logistic regression showed that married people, those who were not satisfied with their health sta-tus and those who perceived they had a greater probability of being infected were at greater risk of anxiety compared

with their counterparts [odds ratio (OR) = 1.57, 95% confidence interval (CI): 1.02–2.40; OR = 1.87, 95% CI: 1.13–3.09; OR = 3.07, 95% CI: 1.94–4.86 respectively] (Table 1). In the multivariate regression analysis, only perception of personal health status and perception of greater probability of be-ing infected were significant predictors of anxiety during the 2014 outbreak (OR = 2.49, 95% CI: 1.31, 4.75; OR = 3.25, 95% CI: 1.86, 5.70 respectively) (Table 1).

Level of anxiety was significantly associated with several avoiding behav-iours, including changing plans for per-forming Umrah, postponing domestic or international travel, avoiding eating outside the home and avoiding visiting hospitals and public places (P < 0.05) (Table 2). Analysis was done among those who responded they had plans for Umrah or travel.

Mean anxiety level was significantly associated with hand washing after

Table 2 Mean anxiety score regarding MERS-CoV infection a sample of adults in Jeddah, 2014, n = 358

Avoiding behaviour Anxiety scorea mean (SD)

P-valueb

Change plan for Umrah

0.001Yes (n = 54, 30.68%) 5.78 (2.35)

No (n = 122, 69.32%) 4.52 (2.17)

Postpone planned domestic travel

0.01Yes, due to MERS CoV (n = 50, 17.36%) 5.66 (2.31)

Yes, not due to MERS CoV (n = 238, 82.64%) 4.74 (2.21)

Postpone planned international travel

0.002Yes, due to MERS CoV (n = 35, 12.23%) 6.09 (2.21)

Yes, not due to MERS CoV (n = 251, 87.76%) 4.79 (2.25)

Avoid eating outside the home

0.001Yes, due to MERS CoV (n = 67, 21.54%) 5.91 (2.41)

Yes, not due to MERS CoV (n = 244, 78.46%) 4.71 (2.17)

Avoid visiting hospitals

0.03Yes, due to MERS CoV (n = 155, 48.29%) 5.34 (2.28)

Yes, not due to MERS CoV (n = 166, 51.71%) 4.78 (2.25)

Avoid public places

0.001Yes, due to MERS CoV (n = 84, 26.33%) 5.89 (2.27)

Yes, not due to MERS CoV (n = 235, 73.67%) 4.67 (2.19)

SD = standard deviation. aScored on a 10 cm visual analogue scale. bMann–Whitney test.

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coughing or sneezing (P = 0.013) and wearing a face mask (P = 0.002) (Table 3).

The main information source for MERS-CoV was television (TV) (50.7%) followed by WhatsApp mes-senger (32.9%) and the Ministry of Health website (30.8%) (Table 4).

Discussion

None of the participants in the current study had ever been diagnosed with MERS-CoV but some knew confirmed cases, of whom the majority had died. A moderate level of anxiety was reported among almost half of the participants. However, overall of knowledge about

the mode of transmission of MERS-CoV, clinical manifestations and pre-vention was modest.

Prevalence of anxiety about MERS-CoV in our study was higher (57.7% scored 5 or more on 10 centimeter VAS) compared with the findings of Rubin et al. where 23.8% scored ≥ 12 out of 24 on the 6-item State-Trait Anxiety Inventory (STAI), suggesting anxiety about swine influenza (26). The higher prevalence of anxiety in our study could be attributed to lack of communication and information about mode of trans-mission and sources of infection and the unique location of Jeddah, very close to Mecca, where there is increased con-cern about spread of infection among pilgrims.

Anxiety was associated with percep-tion of increased susceptibility to infec-tion, in concordance with Cowling et al. (10), as well as satisfaction with general health status.

Only 13.8% of our participants perceived themselves as very likely to acquire MERS-CoV, similar to the find-ings of Lau et al., who reported that 10% of participants considered themselves to have a high or very high chance of contracting influenza A/H1N1 during the prepandemic period (27).

The most common source for infor-mation on the disease in this study was TV, which is consistent with previous studies during other influenza epidem-ics. Akan et al. found the majority of the university students in their study (89%) had received information from the mass media (TV) (28). Also, TV was the major source of information (38.6%) in a study carried out in India during the 2009 H1N1 pandemic (5). This find-ing is important as it demonstrates that mass media (specifically TV) continues as a major source of health information, contrary to the expected shift towards internet sources and other smart mobile applications. An interesting observation in our study was related to the use of new applications (e.g. WhatsApp) and short message services (SMS) as important sources for public awareness. Consider-ing how widespread the use of these applications is among the study popula-tion, they might lead to increased public panic because of rumors and incorrect or insufficient information. Trust in information is an essential element in risk perception (29) and behaviour change (30). During the early stages of an epidemic, and in particular with new emerging infectious diseases like MERS CoV, people seek information from different sources (internet, social media, peers, etc.) if official public health advice is lacking or inadequate (31,32). Health authorities should respond promptly with clear, evidence-based public health information in order to maximize trust

Table 3 Mean anxiety score and personal hygiene behaviour among a sample of adults in Jeddah, 2014, n = 358

Variable Anxiety levela mean (SD)

P-value*

Cover mouth

0.506

Always 4.96 (2.91)

Usually 4.72 (2.92)

Sometimes 4.74 (2.99)

Rarely 4.62 (4.03)

never 5.41 (3.26)

Wash hands after cough or sneeze

0.013

Always 5.48 (3.08)

Usually 5.13 (2.84)

Sometimes 4.67 (2.77)

Rarely 3.79 (2.65)

Never 3.53 (2.93)

Wash hands after coming back home

0.44

Always 5.14 (3.00)

Usually 5.06 (2.70)

Sometimes 4.63 (2.85)

Rarely 3.7 (2.90)

Never 6.25 (3.50)

Wear face mask

0.002

Always 5.47 (3.09)

Usually 6.1 (2.83)

Sometimes 5.64 (2.88)

Rarely 4.92 (2.81)

Never 4.28 (2.91)

SD = standard deviation. aDetermined using a 10 cm visual analog scale. *Kruskal–Wallis test.

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References

1. MERS CoV daily update, 24 December 2015. Riyadh: Com-mand and Control Center, Ministry of Health; 2015 (http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statis-tics-2015-12-17-001.aspx, accessed: 24 December 2015).

2. Middle East respiratory syndrome coronavirus (MERS-CoV) summary of current situation, literature update and risk assessment. Geneva: World Health Organization; (2015 WHO/MERS/RA/15.1) (http://apps.who.int/iris/bit-stream/10665/179184/2/WH))O_MERS_RA_15.1_eng.pdf?ua=1, accessed 24 September 2016).

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and ensure public compliance with pre-ventive behaviours (33).

Awe found that nxiety was associ-ated with several avoidance behaviours and precautions, especially relating to travel or being in public places. This was in consistence with Cowling et al. dur-ing the 2009 influenza H1N1 pandemic (10) and other studies of previous epidemics where a positive correlation between level of anxiety and hygiene measures (28,34,35) and wearing face masks (36) has been reported. How-ever, adherence to health protective behaviours (e.g., hand washing, wearing face masks and social distancing) varies with perceived health threats and ef-fectiveness and the demographic char-acteristics of the population (25,31,37).

Limitations of this study include timing of data collection in June 2014 where the outbreak in Jeddah was de-clining, the cross-sectional nature of the design with an inability to infer causal pathways and the sampling methods, which may preclude generalization to all inhabitants in Jeddah.

In conclusion, the current study showed a moderate level of anxiety and modest knowledge among participants. Level of anxiety was associated with several avoidance behaviours related to the domestic and international travel and being in public places. Wearing face masks and washing hands after cough or sneeze were associated with increased level of anxiety. Traditional sources of information (e.g. TV) continue to have

great impact on the population knowl-edge. However, new applications (e.g. WhatsApp) and short message services (SMS) are important sources for public awareness.

During such outbreaks providing immediate evidence-based information to the public using both traditional me-dia (e.g. TV) and new communications software/applications may be useful in controlling anxiety and associated psychobehavioural responses. Health authorities shouldbe encouraged to take the lead in informing the public about proper prevention and control measures rather than abandoning the stage to the spread of rumors through social media.

Acknowledgements

This research was conducted during the Research Summer School 2014 in King Abdullah International Medical Research Center, Jeddah, Saudi Arabia. The authors would like to thank the participants for their cooperation and the shopping centre administrators for facilitating data collection. Special thanks to AM Khalil, A Samman, A Azab, S Shaikhoon, R Alwasiah AS Reda and B Al-wasyah, who helped in data collection. Funding: None.Competing interests: None declared.

Table 4 Sources of information for the 2014 MERS CoV outbreak among a sample of adults in Jeddah, 2014, n = 358

Source No %

Television 182 50.8

WhatsApp 118 33.0

Ministry of Health website 110 30.7

SMS 96 26.8

Social media 93 26.0

Frienda 92 25.7

Healthcare provider 89 24.9

Internet search (Google) 78 21.8

Newspaper 61 17.0

Medical website 52 14.5

School/university 36 10.1

SMS = short message service. aIncludes direct communication and means other than WhatsApp or SMS.

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20. Williams VS, Morlock RJ, Feltner D. Psychometric evaluation of a visual analog scale for the assessment of anxiety. Health Qual Life Outcomes. 2010 06 08;8:57. 10.1186/1477-7525-8-57 PMID:20529361

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28. Akan H, Gurol Y, Izbirak G, Ozdatli S, Yilmaz G, Vitrinel A, et al. Knowledge and attitudes of university students toward pandemic influenza: a cross-sectional study from Turkey. BMC Public Health. 2010 Jul 13;10:413. PMID:20626872

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35. Leung GM, Lam TH, Ho LM, Ho SY, Chan BH, Wong IO, et al. The impact of community psychological responses on out-break control for severe acute respiratory syndrome in Hong Kong. J Epidemiol Community Health. 2003 Nov;57(11):857–63. PMID:14600110

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1Health Sciences Faculty, Istanbul University, Istanbul, Turkey (Correspondence to: N. Kaya: nurka@istanbul.edu.tr, nurtenkaya66@gmail.com). 2Department of Nursing, Health Sciences Faculty, Bezmi Alem University, Istanbul, Turkey. 3Department of Metallurgy, İnönü Technical and Industrial Vocational High School, Istanbul, Turkey. 4Nişantaşı Nuri Akın Anatolia High School, Istanbul, Turkey. 5Department of Fundamentals of Nursing, Florence Nightingale Nursing Faculty, Istanbul University, Istanbul, Turkey

Received: 09/09/14; accepted: 03/08/16

Association between attitudes towards Internet usage and health practices in high-school students in 2 schools in Turkey: a cross-sectional studyN. Kaya 1, T. Aşti 2, İ. Kaya 3, S. Yaylaci 4, H. Kaya 5, N. Turan 5 and G. Özdemir Aydin 5

ABSTRACT Excessive usage of the Internet can negatively affect health and health practices especially among youth. To examine the issue among Turkish students, this study determined the association between high-school students’ attitudes towards Internet usage and their health behaviour. The sample (n = 2043) was randomly drawn from all students at two high schools in Turkey: one in Anatolia and one (a vocational school) in Istanbul. Data were collected using the Structured Questionnaire, Attitude Scale towards Internet Usage (ASTIU) and Adolescent Lifestyle Profile (ALP). The mean age of the students was 16.3 years, 77.7% were male and 96.9% used the Internet; mean duration of Internet use was 18.8 h/week. Female students had more positive attitudes towards Internet usage. Mean scores for ASTIU and ALP were 72.58 (SD 17.64) and 111.34 (SD 16.61) respectively, which were average levels. There was a statistically significant but weak overall negative correlation between adolescents’ attitudes towards Internet usage and their health behaviour. Our results concur with studies in different cultures which suggest some negative effects, of heavy Internet use.

الرتابط بني االجتاهات جتاه استخدام اإلنرتنت واملامرسات الصحية لدى طالب املرحلة الثانوية يف مدرستني يف تركيا: دراسة مقطعيةنورتان كايا، توركيناز أشتي، آي. كايا، سيف الدين يايالجي، خدجية كايا، نوراي توران، جولسون أوزديمري آيدين

اخلالصــة: يمكــن لالســتخدام املفــرط لإلنرتنــت أن يؤثــر تأثــريا ســلبيا عــى الصحــة وعــى املامرســات الصحيــة والســيام بــن الشــباب. لدراســة هــذا املوضــوع لــدى الطــالب يف تركيــا، حتــدد هــذه الدراســة الرتابــط بــن اجتاهــات طــالب املرحلــة الثانويــة جتــاه اســتخدام اإلنرتنــت وســلوكهم الصحي. تــم اختيــار العينــة )وعــدد أفرادها 2043 طالبــا( عشــوائيا مــن بــن مجيــع الطــالب يف مدرســتن ثانويتــن يف تركيــا: إحدامهــا يف أنطوليــا والثانيــة )وهــي مدرســة مهنيــة( يف إســطنبول. وتــم مجــع البيانــات

باســتخدام اســتبيان مبنــي عــى "مقيــاس االجتاهــات جتاه اســتخدام اإلنرتنــت" و"ملف أنــامط احلياة لــدى املراهقــن". كان متوســط أعــامر الطــالب 16.3 ســنة، وكان 77% منهــم ذكــورا، كــام كان %96.9 منهــم يســتخدمون اإلنرتنــت، وكان متوســط مدة اســتخدامهم اإلنرتنت 18.8 ســاعة أســبوعيا. واتضــح أن للطالبــات اجتاهــات إجيابية أكثر نحــو اســتخدام اإلنرتنــت، وأن متوســط القياســات لســلم قيــاس االجتاهــات جتــاه اســتخدام اإلنرتنــت 72.58 )االنحــراف املعيــاري 17.64( ومللــف أنــامط احليــاة 111.34 )االنحــراف املعيــاري 16.61( ومهــا مــن املســتويات الوســطية. وكانــت هنــاك عالقــة ســلبية ضعيفــة ولكنهــا ذات أمهيــة إحصائيــة بــن اجتاهــات املراهقــن جتاه اســتخدام اإلنرتنــت وبــن ســلوكهم الصحــي. وتتوافــق النتائــج التــي توصلنــا إليهــا مــع نتائــج دراســات أجريــت يف جمتمعــات خمتلفــة وكانــت تشــري إىل بعــض التأثــري الســلبي

ــف لإلنرتنت. لالســتخدام املكث

Association entre les attitudes à l’égard de l’utilisation d’Internet et les pratiques sanitaires des élèves du secondaire dans deux établissements en Turquie : étude transversale

RÉSUMÉ Une utilisation excessive d’Internet peut nuire à la santé et aux pratiques sanitaires, notamment chez les jeunes. Afin d’étudier la question parmi les élèves turcs, la présente étude a déterminé l’association entre les attitudes des élèves du secondaire à l’égard d’Internet et leurs comportements en matière de santé. L’échantillon (n = 2043) a été constitué de façon aléatoire à partir de l’ensemble des élèves de deux établissements d’enseignement secondaire en Turquie : l’un en Anatolie et l’autre dans une école de formation professionnelle à Istanbul. Les données ont été collectées à partir d’un questionnaire structuré, de l’ASTIU [échelle d’attitude à l’égard de l’utilisation d’Internet] et de l’ALP [profil de mode de vie des adolescents]. L’âge moyen des élèves était 16,3 ans, 77 % étaient des garçons et 96,9 % utilisaient Internet, avec une durée moyenne totale d’utilisation de 18,8 heures par semaine. Les élèves de sexe féminin avaient des comportements plus positifs à l’égard de l’utilisation d’Internet. Les scores moyens pour l’ASTIU et l’ALP étaient de 72,58 (ET 17,64) et 111,34 (ET 16,61) respectivement, qui correspondaient aux scores moyens. Il existait une corrélation négative statistiquement significative, mais assez faible d’un point de vue global, entre les attitudes des adolescents à l’égard de l’utilisation d’Internet et leurs comportements en matière de santé. Nos résultats recoupent ceux d’études réalisées dans différentes cultures et qui suggèrent l’existence de certains effets négatifs liés à une utilisation excessive d’Internet.

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Introduction

Internet usage in all fields, such as edu-cation, health, communication, trans-portation, trade and finance, affects the world we live in (1,2). The Internet has become pervasive in the lives of young people and there is evidence that it has a negative effect on academic attain-ment (drop in grades), family relations (having to hide excessive Internet usage from parents), physical health (sleep deprivation due to long hours of Inter-net usage), mental health (depression) and finance (cost of accrued Internet expenses) (3).

For high-school students, the Inter-net is one of the main sources of infor-mation and social interaction (4,5). It enables them to access to information, do research and develop skills such as problem solving, creativity and critical thinking. On the other hand, excessive, uncontrolled and unthinking usage can have a negative effect on the develop-ment of personal skills and health and health practices (6–8). For example, regular physical activity is essential for a healthy productive life. Modern life, with its cars, televisions, computers and video games, can lead to low levels of physical activity and necessitate delib-erate commitment of leisure time to physical activity to gain health benefits (9,10).

Health-risk behaviours are usually adopted in adolescence but their impact may not be felt until adulthood and may lead to a considerable increase in mortality and morbidity. Adolescents are therefore at a critical time in their life for making independent health care decisions; hence health promotion is especially important in this population (11). Health promotion aims to enable individuals to adjust their behaviours to attain a high level of physical and mental health.

As the Internet is an increasingly important resource of information in the lives of young people, it could be a

valuable platform to deliver health in-terventions to youth populations; how-ever, there is a lack of research in this field (12). This study among Turkish adolescents was therefore conducted to examine students’ attitudes to the Internet and their health practices in view of the social norms in Turkey, such as strong family ties (13–15).

The specific aims of this study were to evaluate:

• the attitudes of students towards the Internet usage and their health prac-tices;

• any correlation between Internet us-age and students’ health practices;

• the effect of sociodemographic and Internet-related characteristics on at-titudes towards Internet usage and health practices.

Methods

Study design and sampleThis was a cross-sectional study con-ducted in 2011/12. The study popula-tion consisted of all the students enrolled at one Anatolian high school and one vocational high school in Istanbul (total number of students = 3955). Students were selected randomly from each school separately (by drawing names from separate bags for Anatolian and Istanbul students); thus 310 students were selected from the Anatolian high school and 1733 from the vocational high school in Istanbul (Table 1).

We conducted post hoc power analysis using G*Power 3.1.9.2 program. A significant difference was observed in the ASTIU scores (z = 3.66, P < 0.001) between Internet users and non-users (Table 2). The statistical power analysis result for this difference was 0.97.

Data collectionData were collected by the researchers through face-to-face interviews with the students outside the classroom lessons

using three data collection tools (Struc-tured questionnaire, Attitude Scale to-wards Internet Usage and Adolescence Lifestyle Scale). The interviews were conducted in Turkish. To reduce social desirability bias, a randomized response technique was used (16,17).

Data collection toolsStructured Questionnaire: It includ-ed questions regarding students’ age, sex, body mass index (BMI) as meas-ured by the researchers, and computer and Internet usage.Attitude Scale towards Internet Usage (ASTIU): It was designed by Tavşancıl and Keser to assess attitudes towards Internet usage (18). It consists of 6 sub-dimensions: Usage of Inter-net in Instruction, Usage of Internet in Research, Usage of Internet in Social Interaction, Enjoyment of Usage of Internet in Instruction, Usage of In-ternet in Communication and Usage of Internet in Sharing of Knowledge. The 5-point Likert type scale consists of 31 items. The lowest and highest scores are 31 and 155 respectively. The higher the score in all sub-dimensions, the more positive the attitude towards Internet usage (amount and type of Internet use). The internal consistency coefficient for the whole scale was 0.89 (18). In the present study, the internal consistency coefficient was 0.88, indi-cating ASTIU was a valid assessment tool for our study.Adolescent Lifestyle Profile (ALP): The ALP is the version of Healthy Lifestyle Profile II developed for adolescents (9). Validity and reliability studies were conducted by Hendricks, Murdaugh and Pender (9) , and a Turkish version was adapted by Ardıç (10). ALP consists of 40 items and 7 sub-dimensions: health responsibility, physical activity, nutrition, positive life appreciation, interpersonal relations, stress management, and spiritual growth. The lowest and highest scores obtainable are 40 and 160 respectively. The higher the score, the higher the level

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of health practice. The Cronbach alpha coefficient for the whole scale was 0.87, range 0.54 to 0.77 for sub-dimensions (9). For the present study, it was 0.89 for the whole scale, range 0.53 to 0.72 for sub-dimensions. Internal consistency coefficients in our study were similar to Ardıç’s (10), thus scale-related values had internal consistency.

Statistical analysisSPSS 17 for Windows (version 11.0; SPSS Inc., Chicago, IL, USA) was used to analyse the data. Medians, minimum and maximum values and arithmetic means [standard deviation (SD)] were used for ordinal data evaluation. Frequency and percentages were used for nominal data evaluation. The Kol-mogorov–Smirnov test was used to determine normality of distributions. As some distributions were abnormal, non-parametric methods were used for the statistical analysis. When comparing qualitative data, the Mann–Whitney U test was used to compare variables be-tween two groups. The Kruskal–Wallis test was used to compare variables with more than two groups. The Bonferroni-adjusted Mann–Whitney test was used to identify the responsible group for the difference with secondary multiple comparison analysis when the differ-ences between the parameters of more than 2 groups were found statistically significant. Spearman correlation analy-sis was used to determine correlation between scales.

Ethical considerationsPrior to the study, authorized writ-ten approval was obtained from the Faculty of Medicine Ethics Commit-tee, Istanbul University Cerrahpaşa

(03.02.2011/8087/C-07) and the Istanbul Provincial Directorate for Na-tional Education (02.04.2011/19532). Student participants were informed about the aims and benefits of the study and their roles were explained; all agreed to participate. Their written ap-proval was taken on the consent form. No names were entered on the data collection forms and they were kept separately from the consent form to protect the anonymity of the students.

Results

Students’ characteristicsOf the 2043 students included in the study, 1587 (77.7%) were male. The reason for the difference was due to the higher number of male students in the vocational high school. The age of the participants ranged from 14 to 19 years, mean age was 16.3 years; just over half (55.2%) were aged 14–16 years. In addition, 70.4% were at a normal weight in terms of BMI, 68.4% had personal computers and 96.9% used the Internet. The mean duration of Internet use was 18.8 hours per week (SD = 17.0) (Table 2).

Association between sociodemographic & Internet-related characteristics and ASTIU & ALP scoresSex was significantly associated with ASTIU score; female students had more positive attitudes towards the In-ternet usage (P < 0.001) (Table 2). Age was not significantly associated with either ASTIU or ALP scores (P > 0.05) (Table 2).

BMI was significantly associ-ated with ALP scores (P < 0.05). The

difference between BMI groups re-sulted from the differences in scores obtained by normal-weight and over-weight students (X 2 = 8.28, P = 0.041). In line with this finding, the students with normal weight had more positive lifestyle practices compared to over-weight students (Table 2).

The students with personal com-puters had significantly lower ASTIU scores (P < 0.001) than those who did not own one. However, the opposite was true for ALP scores with computer-owning students having higher ALP scores (P < 0.001). This finding shows that students owing a computer had more negative attitudes towards the In-ternet usage but reported more positive lifestyle practices than those not owning a personal computer (Table 2).

ASTIU scores of those using the Internet were also significantly lower than those who did not do so (P < 0.05), indicating that students using the Inter-net had more negative attitudes towards the Internet than non-users (Table 2).

ASTIU and ALP scores were associ-ated with weekly duration of Internet usage; the longer the Internet usage of students, the more negative were their attitudes towards Internet usage and the more negative their health practices (Table 2).

ASTIU & ALP scores and correlations between themThe mean (SD) ASTIU score was 72.58 (SD 17.64). For sub-dimensions, the mean (SD) scores were: 17.87 (SD 6.03) for Usage of Internet in Instruc-tion, 16.16 (SD 4.65) for Usage of Internet in Research, 10.44 (SD=4.38) for Usage of Internet in Social Interac-tion, 10.54 (SD 3.26) for Enjoyment

Table 1 Distribution of population (N = 3955) and sample (n = 2043)

Institution Total no. of students (Si) Sample weight (ai)a No. of students in sampleb

Anatolian high school 600 0.15 310

Vocational high school 3355 0.85 1733aai = Si/N. bai × n.

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of Usage of Internet in Instruction, 9.26 (SD 3.35) for Usage of Internet in Communication, and 8.32 (SD 3.57) for Usage of Internet in Sharing of Knowledge. For ALP, the mean (SD) score for the whole scale was 111.34 (SD 16.61). The mean (SD) scores for sub-dimensions were: 10.69 (SD 2.91) for health responsibility, 16.08 (SD 3.76) for physical activity, 15.97 (SD 3.23) for nutrition, 24.38 (SD 4.35) for positive life appreciation, 15.54 (SD 2.89) for interpersonal relations, 14.68 (SD 2.70) for stress management, and 13.99 (SD 2.92) for spiritual growth (Table 3).

While there was no correlation between students’ attitudes towards the Internet usage and health responsi-bility, a very weak negative correlation was found between students’ attitudes towards Internet usage and physical activity, nutrition, positive outlook on life, interpersonal relations, stress man-agement, spiritual growth and general lifestyle practices (Table 4).

Discussion

Overall, we found a very weak negative association between attitudes towards the Internet usage and adolescents’ health practices.

With regard to students’ individual characteristics and Internet usage, we found that the majority of participants used both computers and the Inter-net, and more than half of them had their own personal computer. Simi-larly, a study conducted by Cömert and Kayıran among children and adoles-cents showed that 35.7% of the families had a computer in their homes and 21.7% had Internet access (19). Given the fact that the Internet facilitates ac-cess to information, the high access shown in our study is overall a positive finding because students can easily ben-efit from the opportunities afforded by the Internet.

Table 2 Distribution of students’ scores in ASTIU and ALP according to the individual and Internet-related characteristics (n = 2043)

Variable No. (%) ASTIU ALP

Mean (SD) Mean (SD)

Sex

Female 456 (22.3) 76.18 (16.75) 111.08 (14.32)

Male 1587 (77.7) 71.54 (17.75) 111.42 (17.22)

z = −5.60, P < 0.001 z = −0.36, P = 0.720

Age groups (years)

14–16 1127 (55.2) 72.26 (16.88) 111.80(16.18)

17–19 916 (44.8) 72.97 (18.53) 110.78 (17.12)

z = −0.47, P = 0.640 z = −0.82, P = 0.413

Mean (SD), (Min–Max) 16.29 (0.99), (14−19) r = 0.134, P = 0.146 r = 0.170, P = 0.064

Body mass index

< 18.50 (underweight) 337 (16.5) 71.89 (16.95) 110.39 (17.03)

18.50–24.99 (normal) 1439 (70.4) 73.00 (17.59) 111.93 (16.58)

25–29.99 (overweight) 229 (11.2) 71.47 (19.09) 108.85 (16.33)

30 (obese) 38 (1.9) 69.13 (16.23) 112.45 (14.46)

χ2 = 5.70, P = 0.127 χ2 = 8.28, P = 0.041

Owns computer

Yes 1397 (68.4) 70.52 (17.34) 112.54 (16.42)

No 646 (31.6) 77.02 (17.47) 108.75 (16.74)

z = −8.16, P < 0.001 z = −4.52, P < 0.001

Uses the Internet

Yes 1979 (96.9) 72.31 (17.56) 111.38 (16.60)

No 64 (3.1) 80.77 (18.06) 110.25 (16.98)

z = −3.66, P < 0.001 z = −0.87, P = 0.385

Duration of Internet usea (h/week)

(Mean (SD), (Min–Max)) 18.75 (17.01), (1–93) r = −0.198, P < 0.001 r = −0.084, P < 0.001aExamined in the 1979 individuals who used the Internet. z = Mann−Whitney U test; χ2 = Kruskal−Wallis test. Statistical significant set at P < 0.05. ASTIU = Attitude Scale towards Internet Usage; ALP = Adolescent Lifestyle Profile; SD = standard deviation.

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In the current study, significant sex differences in Internet usage were ob-served; male students used the Internet more than females. Other studies have shown sex differences in amount and type of Internet use, but not consist-ently for one sex or the other (20–22). Macharia & Nyakwende found that female university students in Kenya reported greater use of the Internet for study purposes than males (20). Simi-larly, a study conducted among high school students in Turkey reported that female students spent more time than male students on the Internet (6). However, a study in Australia observed that male adolescent students spent more time on the Internet than their female counterparts (21). Males in the United States of America were reported to use the Internet mainly for purposes related to entertainment and leisure whereas women used it primarily for interpersonal communication and edu-cational assistance (22).

The correlation between the dura-tion of the Internet use and ASTIU and ALP scores showed that longer Internet usage was associated with more nega-tive attitudes towards its use and poorer health practices. Several studies confirm the negative effects of Internet use on health practices if it is used for extended periods of time. A study among students in Hong Kong reported that heavy In-ternet users were much less likely than others to engage in health-promoting behaviours such as attempting to eat a healthier diet, taking nutritional supple-ments and trying to increase physical activity levels (23). In a study among Turkish high-school students, Kelleci et al. showed that Internet usage in excess of 2 hours a day led to mental health disorders (6). Among a sample of adults (median age of 20 years), higher lev-els of computer usage were associated with both lower physical activity lev-els and perception of computer usage as a barrier to physical activity (24). Moreover, Morgan and Cotton, and Yang et al. suggested that excessive use

of the Internet caused students to devi-ate from the real life and fail to cope with difficulties they encounter (25,26). Participants of a study conducted by Rotunda et al. reported certain negative outcomes of Internet usage and that problematic practices, which were less prevalent, became more common (27).

The students’ ASTIU scale total score was at a medium level (mean 72.58 in a range of 31–155). Also Internet Usage in Instruction was the sub-dimension on which students got the highest scores. A study among adolescents in Lebanon indicated that 84.2% the Internet usage was for com-munication and messaging, 65.7% for information and research, 51.8% for en-tertainment such as gaming, 51.2% for music and movies, and 4.6% for other purposes (28). Thanks to its interac-tive nature, the Internet contributes to education and provides resources and materials in almost every field that can be used directly in the classroom. Fur-thermore, students in this information

Table 3 Distribution of students’ scores from the Attitude Scale towards Internet Usage (ASTIU) and Adolescent Lifestyle Profile (ALP) scales (n = 2043)

Scale Potential range

Minimum Maximum Median Mean (SD)

ASTIU

Usage of the Internet in instruction 8–40 8 40 17 17.87 (6.03)

Usage of the Internet in research 7–35 7 35 16 16.16 (4.65)

Usage of the Internet in social interaction 4–20 4 20 10 10.44 (4.38)

Enjoyment from usage of the Internet in instruction 4–20 4 20 10 10.54 (3.26)

Usage of the Internet in communication 4–20 4 20 9 9.26 (3.35)

Usage of the Internet in sharing of knowledge 4–20 4 20 8 8.32 (3.57)

Total 31–155 31 148 72 72.58 (17.64)

ALP

Health responsibility 5–20 5 20 10 10.69 (2.91)

Physical activity 6–24 6 24 16 16.08 (3.76)

Nutrition 6–24 6 24 16 15.97 (3.23)

Positive life appreciation 8–32 8 32 25 24.38 (4.35)

Interpersonal relations 5–20 5 20 16 15.54 (2.89)

Stress management 5–20 5 20 15 14.68 (2.70)

Spiritual growth 5–20 5 20 14 13.99 (2.92)

Total 40–160 40 160 111 111.34 (16.61)

SD = standard deviation.

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Tabl

e 4

Cor

rela

tion

bet

wee

n st

uden

ts’ s

core

s on

the

Att

itude

Sca

le to

war

ds In

tern

et U

sage

(AST

IU) a

nd A

dole

scen

t Life

styl

e Pr

ofile

(ALP

) sca

les

(n =

20

43)

ALP

AST

IU

Usa

ge o

f the

In

tern

et in

in

stru

ctio

n

Usa

ge o

f the

In

tern

et in

rese

arch

Usa

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f the

In

tern

et in

soc

ial

inte

ract

ion

Enjo

ymen

t fr

om u

sage

of

the

Inte

rnet

in

inst

ruct

ion

Usa

ge o

f the

In

tern

et in

co

mm

unic

atio

n

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ge o

f the

In

tern

et in

sha

ring

of

kno

wle

dge

Tota

l

Hea

lth

resp

onsi

bilit

y

r a–0

.080

**0

.070

**–0

.048

*0

.016

0.0

91**

0.0

170

.00

3

P b

< 0

.00

10

.00

20

.028

0.4

77<

0.0

01

0.4

350

.90

1

Phys

ical

act

ivity

r a–0

.178**

–0.0

89**

–0.16

0**

–0.13

4**–0

.071

**–0

.147**

–0.19

2**

P b

< 0

.00

1<

0.0

01

< 0

.00

1<

0.0

01

0.0

01

< 0

.00

1<

0.0

01

Nut

riti

on

r a–0

.107**

–0.0

33–0

.043

–0.0

49*

0.0

11–0

.069

**–0

.077

**

P b

< 0

.00

10

.139

0.0

530

.027

0.6

170

.00

20

.00

1

Posi

tive

life

app

reci

atio

n

r a–0

.158**

–0.15

7**–0

.057

**–0

.095

**–0

.141**

–0.18

2**–0

.191**

P b

< 0

.00

1<

0.0

01

0.0

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0.0

01

< 0

.00

1<

0.0

01

< 0

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1

Inte

rper

sona

l rel

atio

ns

r a–0

.137**

–0.16

4**–0

.040

–0.0

55*

–0.13

8**–0

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–0.16

8**

P b

< 0

.00

1<

0.0

01

0.0

690

.013

< 0

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1<

0.0

01

< 0

.00

1

Stre

ss m

anag

emen

t

r a–0

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–0.11

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–0.15

5**

P b

< 0

.00

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0.0

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0.0

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< 0

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0.0

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1

Spir

itual

gro

wth

r a–0

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–0.0

76**

–0.13

0**

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9**

P b

< 0

.00

10

.00

1<

0.0

01

< 0

.00

10

.00

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0.0

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Tota

l

r a–0

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–0.11

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.090

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–0.19

2**

P b

< 0

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he 0

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0.01

leve

l (2-

taile

d).

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830

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A main limitation to our study is that it was conducted in only 2 schools is Turkey and the sample may not be representative of schools across Turkey; hence the results may not be general-ized to a wider population.

Conclusion

This current study was conducted to determine the effects of high school

students’ attitudes towards the Internet usage on their health practices. Weak negative correlations were found be-tween students’ attitude towards the Internet usage and physical activity, nutrition, positive outlook on life, inter-personal relations, stress management, spiritual growth, and general lifestyle practices. Thus it may be said that In-ternet use appears to have little effect on students’ health practices. However, while showing weak effects, our results are similar to studies in different cultures which suggest some negative effect of heavy Internet use; some control of the heavy usage of the Internet may be warranted.

Acknowledgements

We would like to thank Istanbul Uni-versity Scientific Research Projects Unit for funding the research.Funding: Istanbul University Scientific Research Projects Unit (Project Num-ber: 17720).Competing interests: None declared.

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18. Tavşancıl E, Keser H. İnternet kullanımına yönelik likert tipi bir utum ölçeğinin geliştirilmesi [Development of a Likert type attitude scale towards Internet usage]. Eğitim Bilimleri ve Uygu-lama Dergisi. 2002;1(1):79–100.

19. Cömert IT, Kayıran SM. Çocuk ve ergenlerde internet kullanımı [Internet use among children and adolescents]. Çocuk Dergisi. 2010;10(4):166–70.

20. Macharia J, Nyakwende E. Gender differences in internet usage intentions for learning in higher education: An empirical study. Journal of Language Technology & Entrepreneurship in Africa. 2011;3(1):244–54.

21. Wang W. Internet dependency and psychosocial maturity among college students. International journal of human-computer studies. 2001;55:919–38.

22. Weiser EB. Gender differences in Internet use patterns and Internet application preferences: A two-sample comparison. Cyberpsychology & Behavior. 2000;3(2):167–78.

23. Kim JH, Lau CH, Cheuk KK, Kan P, Hui HL, Griffiths SM. Brief report: Predictors of heavy Internet use and associations with

health-promoting and health risk behaviors among Hong Kong university students. J Adolesc. 2010 Feb;33(1):215–20.

24. Fotheringham MJ, Wonnacott RL, Owen N. Computer use and physical inactivity in young adults: public health perils and potentials of new information technologies. Ann Behav Med. 2000 Fall;22(4):269–75.

25. Morgan C, Cotten SR. The relationship between internet activi-ties and depressive symptoms in a sample of college freshmen. Cyberpsychol Behav. 2003 Apr;6(2):133–42.

26. Yang CK, Choe BM, Baity M, Lee JH, Cho JS. SCL-90-R and 16PF profiles of senior high school students with excessive internet use. Can J Psychiatry. 2005 Jun;50(7):407–14.

27. Rotunda RJ, Kass SJ, Sutton MA, Leon DT. Internet use and mis-use. Preliminary findings from a new assessment instrument. Behav Modif. 2003 Sep;27(4):484–504.

28. Hawi NS. Internet addiction among adolescents in Leba-non. Comput Human Behav. 2012;28(3):1044–53 10.1016/j.chb.2012.01.007.

29. Özmutaf MN, Özgür Z, Gökmen F. Üniversite öğrencilerinin bilgisayar kullanımında birey sağlığı kapsamında genel bakış açıları [General point of view of the university students on computer usage in context of personal health]. Ege Tıp Dergisi [Ege Journal of Medicine]. 2008;47(2):81–6.

30. Ceyhan AA. Ergenlerin problemli internet kullanım düzey-lerinin yordayıcıları [Predictors of adolescents’ problem-atic Internet use levels]. Cocuk Ve Genclik Ruh Sagligi Dergisi. 2011;18(2):85–94.

31. Beard KW. Internet addiction: current status and implications for employees. J Employ Couns. 2002;39:2–11.

32. Wang W. Internet dependency and psychosocial maturity among college students. International Journal of Human-Computer Studies. 2001;55:919–38.

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1 International Training and Education Center for Health, Department of Global Health, Schools of Public Health and Medicine, University of Washington, Seattle, United States of America (Correspondence to: L.A. Perrone: perronel@uw.edu). 2 Interactive Outcomes LLC, Seattle, United States of America. 3 Institute for Health Metrics and Evaluation, Department of Global Health, University of Washington, Seattle, United States of America. 4 World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Received: 14/09/15; accepted: 14/07/16

Short communication

Implementation of a mentored professional development programme in laboratory leadership and management in the Middle East and North AfricaL.A. Perrone,1 D. Confer,1 E. Scott,1 L. Livingston,2 C. Bradburn,1 A. McGee,1 T. Furtwangler,1 A. Downer,1 A.H. Mokdad,3 J.F. Flandin,1 S. Shotorbani,1 H. Asghar,4 H.E. Tolbah,4 H.J. Ahmed,4 A. Alwan 4 and R. Martin 1

ABSTRACT Laboratories need leaders who can effectively utilize the laboratories’ resources, maximize the laboratories’capacity to detect disease, and advocate for laboratories in a fluctuating health care environment. To address this need, the University of Washington, USA, created the Certificate Program in Laboratory Leadership and Management in partnership with WHO Regional Office for the Eastern Mediterranean, and implemented it with 17 participants and 11 mentors from clinical and public health laboratories in 10 countries (Egypt, Iraq, Jordan, Lebanon, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, and Yemen) in 2014. Designed to teach leadership and management skills to laboratory supervisors, the programme enabled participants to improve laboratory testing quality and operations. The programme was successful overall, with 80% of participants completing it and making impactful changes in their laboratories. This success is encouraging and could serve as a model to further strengthen laboratory capacity in the Region.

تنفيذ برنامج للتطوير املهني بالتوجيه يف جمال قيادة وإدارة املختربات يف الرشق األوسط وأفريقيالــويس بــرون، ديبــورا كونفــر، إليزابيــث ســكوت، لورا ليفينغســتون، كاتلــني برادبــورن، أليكس مــاك غي، تــوم فورتوانغلــر، آن داونــر، عيل مقــداد، جني

فريدريــك فالنديــن، ســاملاز شــوتورباين، هومايــون أصغر، هـــ. ي. طلبــة، هـ. جــي. أمحد، عالء العلــوان، روبــرت مارتني

اخلالصــة: حتتــاج املختــرات لقــادة يمكنهــم االنتفــاع ممــا فيهــا مــن مــوارد بفعاليــة، وتعظيــم قدراهتــا ألقــى قــدر يتيــح كشــف األمــراض، ويدافعــون عنهــا يف بيئــة متقلبــة للرعايــة الصحيــة. ولتلبيــة هــذه احلاجــة، أنشــأت جامعــة واشــنطن يف الواليــات املتحــدة األمريكيــة برناجمــا لنيــل شــهادة القيــادة واإلدارة للمختــرات بالراكــة مــع املكتــب اإلقليمــي لــرق املتوســط ملنظمة الصحــة العامليــة، ويف عــام 2014 تم تنفيــذ الرنامج الــذي ضم 17 مشــاركا هــا ينتمــون إىل املختــرات الرسيريــة وخمتــرات الصحــة العامــة يف 10 بلــدان )مــر والعــراق واألردن ولبنــان واملغــرب وعــان وباكســتان وقطر و 11 موجواململكــة العربيــة الســعودية واليمــن(. وانطالقــا مــن كــون الرنامــج قــد تــم تصميمــه لتعليــم املرفــني عــى املختــرات مهــارات القيــادة واإلدارة، فقد وفــر الرنامــج للمشــاركني فيــه إمكانيــة حتســني جــودة االختبــارات والعمليــات. ولقــد كان الرنامــج ناجحــا عــى وجــه اإلمجــال، فقــد أكمــل %80 من املشــاركني مشــاركتهم بــه، وأحدثــوا تغيــرات ذات مــردود ملحــوظ يف املختــرات التــي يعملون فيهــا. ويبدو نجــاح الرنامج مشــجعا ويمكــن أن يكون

نموذجــا لتطويــر املزيــد مــن القــدرات يف املختــرات يف اإلقليم.

Mise en œuvre d’un programme de mentorat en développement professionnel pour les directeurs et les cadres de laboratoire au Moyen-Orient et en Afrique du Nord

RÉSUMÉ Les laboratoires ont besoin de directeurs à même d’utiliser les ressources internes de façon efficace, de maximiser leurs capacités à dépister les maladies, et d’œuvrer pour le bien de ces établissements dans un environment de soins de santé en perpétuel changement. Pour répondre à ces besoins, l’Université de Washington (États-Unis), en partenariat avec le Bureau régional de l’OMS pour la Méditerranée orientale, a mis au point le Programme de certification en direction et gestion de laboratoire qui a été suivi par 17 participants et 11 mentors issus de laboratoires de santé clinique et publique dans 10 pays (Arabie saoudite, Égypte, Iraq, Jordanie, Liban, Maroc, Oman, Pakistan, Qatar et Yémen) au cours de l’année 2014. Conçu pour former les responsables de laboratoire aux compétences de direction et de gestion, le programme a permis aux participants de renforcer la qualité du dépistage et des opérations de leurs laboratoires. Le programme a été une réussite dans l’ensemble puisqu’il a été suivi jusqu’à son terme par 80 % des participants et que ceux-ci ont ensuite pu mettre en place des changements réels dans leurs laboratoires. Ce succès est encourageant et pourrait servir de modèle afin de renforcer davantage encore les capacités des laboratoires dans la Région.

املجلد الثاين و العرشوناملجلة الصحية لرشق املتوسطالعدد احلادي عرش

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Introduction

Countries around the world have been implementing the International Health Regulations (IHR) since 2007, requir-ing all countries to detect, assess, notify, and respond to public health threats (1–3). Health laboratories are a key component of this response and qual-ity practice is essential, unfortunately, many countries are falling behind in these capabilities (3–5). Laboratories are complex, people-driven systems that require strong leadership and effective management to deliver accurate, timely and reliable test results (6,7). Unfortu-nately, many laboratory leaders have not had formal management training or experience leading organizations (8–10). While some training programmes exist, most have been designed for audi-ences in the United States of America, are proprietary or fee-based, lack formal mentorship, are offered exclusively on-line without opportunity to meet faculty or fellow participants, and have lacked a curriculum that addresses core compe-tencies (8,10–18). While field epidemi-ology training programmes have been envisioned as a mechanism to deliver laboratory management training, they have historically focused on the labora-tory’s role in outbreak response and have lacked a structured curriculum in laboratory management and leadership. Additionally, some donors have funded trainings through disease-specific pro-grammes. There remains a global need to strengthen laboratory capacity and quality from a systems approach (19).

Because of these gaps, we developed a competency-based, blended-learning, mentored professional development programme in health laboratory lead-ership and management which can be tailored to local environments and implemented globally. The Certificate Programme in Laboratory Leader-ship and Management (CPLLM) was designed to strengthen the leadership and management skills of laboratory supervisors with the goal of improving

their laboratories’ operations (8,10) and advancing national and regional progress in disease detection and re-sponse, laboratory quality and biosafety and biosecurity.

Methods

Programme design The CPLLM was structured into an in-person programme orientation and course on laboratory systems, 4 online courses, and the applied Capstone Pro-ject (Figure 1). Learning objectives were aligned with key laboratory leadership competencies (8,10). Adult learning programmes that include components of work-based training significantly impact attainment of competencies and behaviour change (20–24). Accord-ingly, the CPLLM’s Capstone Project component was an individualized op-portunity for participants to address areas in their laboratories’ operations that needed improvement; expand and apply leadership, management, ana-lytical, and communication skills; and implement principles of continuous quality improvement. Capstone Project assignments reinforced these concepts and were due during breaks in course-work.

Curriculum development The curriculum for the CPLLM (Figure 1) was developed using adult learning methodologies, and included 1 course delivered in person, 4 online courses [including > 85 recorded lectures and videos, interactive assignments, read-ings, quizzes, and surveys, all accessible through a learning management system (LMS, Canvas™)] (20 –23,25). Each online course lasted 4 weeks (except for Laboratory Leadership and Manage-ment, which was 8 weeks) and required 20–25 hours of work. Participants spent 5–6 hours per week on coursework and Capstone Project work.

The Canvas™ learning management system is an internet-based application

used for the delivery, administration, monitoring and evaluation of the CPLLM; a University of Washington survey indicated that 79% of users prefer this interface to other learning management systems (26,27). Can-vas™ was customized for the CPLLM, and was a central gateway where par-ticipants and mentors could access all programme content, including reading materials, videos, lectures and links to resources—all organized into modules for easy navigation. Participants could also download all materials for offline viewing. Canvas™ contained robust capabilities for communication and col-laboration, including discussion boards, messaging, email, schedule notifications and announcements, and allowed post-ing of multiple file types, including voice and video. Each online course was led by an instructor and teaching assistant, who monitored participants’ assign-ments, guided online discussions and provided support as needed.

Participant recruitment and selection

To facilitate appropriate candidate re-cruitment within multiple ministries of health, a detailed profile was developed which described the required experi-ence of participants. The ideal partici-pant would be a director or manager in a public clinical or public health labora-tory (mid-career); hold a Bachelor’s degree (or equivalent) with > 5 years experience in laboratory medicine, > 1 year in a supervisory role, regarded as an emerging leader with strong motivation for laboratory improvement and self-improvement. Recruitment began in September 2013; 3 candidates from the public sectors in Egypt, 2 each from Iraq, Jordan, Oman, Pakistan, Qatar, Saudi Arabia and Yemen, and 1 each from Lebanon and Morocco were accepted. Selected participants had no previous training in leadership or management.

EMHJ • Vol. 22 No. 11 • 2016 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale

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Courses Units

Pre-

test

Labo

rato

ry

Ass

essm

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k Pl

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test

Pre-

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test

Pre-

test

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ems

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ount

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t and

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dget

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and

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vent

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&

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ple

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agem

ent a

nd

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spor

t

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prov

emen

t To

ols a

nd

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niqu

es

Day

6Pr

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lysi

s an

d Im

prov

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t &

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bora

tory

Day

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form

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anag

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& L

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& T

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ldin

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test

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ts

& M

easu

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rato

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25 H

ours

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lysi

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C

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orat

ory

Info

rmat

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(~25

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rs

Onl

ine)

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and

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gula

tion

(~25

Hou

rs

Onl

ine)

Impl

emen

tati

on

of D

iagn

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c Te

chno

logy

(~25

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rs

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ine)

Labo

rato

ry

Lead

ersh

ip a

nd

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agem

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2(~

25 H

ours

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nlin

e)

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ston

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t(~

60-1

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rs

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ount

ry a

nd

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ine)

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ing

and

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agin

g Fr

amew

ork

&

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ty

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ader

ship

(S

elf-A

sses

smen

t)

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king

with

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ther

s Par

t A

(Tea

m B

uild

ing,

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perv

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n &

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eleg

atio

n)

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king

with

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ther

s Par

t B

(Con

flict

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anag

emen

t an

d In

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ce &

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rsua

sion

)

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istic

al A

naly

sis

of D

ata

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anag

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M

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cien

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nd

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test

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test

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test

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املجلد الثاين و العرشوناملجلة الصحية لرشق املتوسطالعدد احلادي عرش

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Mentor recruitment and participationMentorship in the laboratory can im-prove worker performance (28–30) and mentors played an important role in the CPLLM. A detailed profile was developed and used to recruit qualified mentors and 11 were selected for their reputations as leaders in health labora-tory practice, their experience in labora-tory management, their reputations as results-driven and skilled problem solv-ers, and as communicative and encour-aging teachers. Mentors were coached on mentoring skills at the programme kickoff meeting and throughout imple-mentation. Each mentor supported 1–2 participants, both remotely (Canvas™, Skype™ or telephone) and in-person. Average time commitment to each par-ticipant was approximately 1–2 hours per week throughout the 9-month programme, and mentors helped par-ticipants address barriers to Capstone Project implementation and evaluated their leadership and management skills. Mentors also contributed to the online discussions where appropriate.

Programme implementationThe CPLLM began in Casablanca, Mo-rocco in January 2014. At the orientation session, participants gave presentations about their laboratories and conveyed their goals for the programme. Orienta-tion included an introduction to the purpose, goals and expectations of the programme, an overview of the online curriculum, Canvas™ and the Capstone Project assignments. The Laboratory Systems course followed, covering the roles and requirements of laboratories in a health system, elements of a function-ing laboratory system and laboratory quality management (31). Participants then returned to their laboratories to conduct a laboratory self-assessment (32) and began the online portion of the CPLLM. Capstone Project work began in February with a comprehen-sive laboratory assessment; participants used thesresults to develop the goals and work plans for their Capstone Project. The Capstone Project had to have a direct, practical value within the laboratory, involve the laboratory staff and demonstrate leadership and

management skills. Participants com-pleted 7 Capstone Project assignments during the CPLLM and summarized their findings at the programme finale in September 2014.

Programme evaluation Programme success and curriculum quality were based on a number of indi-cators (33), including programme com-pletion rate, Capstone Project quality, discussion quality and participant and mentor feedback, and was evaluated by both quantitative and qualitative methods (24,33,34). Surveys assessed learner satisfaction with content, and pre/post-course tests, and in-course quizzes and assignments measured par-ticipants’ comprehension; Capstone Project assignments demonstrated the application of course theory. Participant and mentor input on discussion boards was also evaluated. Course evaluations collected quantitative and qualitative data about each course. Programme evaluations were also requested from mentors. Participant progress has also been monitored since completion of

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Ave score after

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*

**

Figure 2 Laboratory capacity self- assessment scores before and after the programme Participants completed comprehensive assessments to evaluate their laboratory’s operations in 11 areas. Average capacity scores improved by 11% during the 9 month-long programme and were the result of participants work on their capstone projects

EMHJ • Vol. 22 No. 11 • 2016 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale

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the CPLLM, measured by informal survey.

Results

The CPLLM was highly success-ful with 14 (80%) of the participants completing the programme and mak-ing substantial improvements in their laboratories, particularly in the areas of quality management and biosafety and biorisk management (Figure 2). All participants improved their leader-ship and management skills and their laboratories’ performance during the programme. They also stated that course content was useful to their jobs, and said they would recommend the CPLLM to their peers. Participants indicated that mentors communicated frequently, that the frequency and du-ration of communications with their mentors were adequate and that their mentors were helpful, providing advice and feedback during the programme. Participant and mentor feedback ses-sions were also conducted at the finale meeting to get qualitative input on the programme (Table 1). This feedback was overwhelmingly positive, with the majority of responses indicating satis-faction with the programme.

Discussion

We developed the CPLLM to address the global need for improved labora-tory management and leadership. It was designed for a global audience and fostered networking and collaboration, strengthening laboratory systems at the national and regional levels. The CPLLM achieved a high graduation rate due to a number of critical factors (33). First, appropriate participants were recruited and we ensured they had the support of their organizations and

recognition by their supervisors. Strong mentorship and collective problem-solving helped ensure retention of participants in the online environment. Feedback received from this cohort was used to further refine the curriculum and optimize participant satisfaction for CPLLM implementation in other countries (the CPLLM is being imple-mented in Zambia in 2016).

Importantly, the CPLLM was high-ly regarded by participants because it delivered both theoretical and practical applications of effective laboratory lead-ership and management. The Capstone Project was a unique component of the CPLLM because it exemplified lead-ership and management theory, and resulted in measureable improvements within a short period of time, unifying the entire laboratory around a common goal. By developing strategic thinking skills, embracing process improvement and learning how to lead change, labo-ratory managers improved laboratory performance. Since programme com-pletion in September 2014, many par-ticipants have communicated that they have started preparing for ISO 15189 accreditation using the new WHO Laboratory Quality Stepwise Imple-mentation (LQSI) tool (35). While financial support for this cohort did not support long-term impact evaluations, these would be ideal to incorporate in future years.

The CPLLM affirms the impact of formal leadership and management training on laboratory capacity, and can build on previous investments for improved laboratory system oper-ability and preparedness (36,37); the modular online curriculum allows the CPLLM to be customized with loca-tion-specific case studies for any coun-try. The CPLLM was provided at no cost to participants thanks to generous United States of America government

grants. However, for sustainability of the programme, user-fees and twinning partnerships with local universities may be pursued for future implementation. Additionally, continuing professional development credits could be pursued with national health professions asso-ciations, and may improve workforce retention (38–40).

Acknowledgements

The authors wish to thank the World Health Organization and the minis-tries of health from Egypt, Iraq, Jordan, Lebanon, Morocco, Oman, Pakistan, Qatar, Saudi Arabia and Yemen for their assistance with participant and mentor recruitment. The authors wish to thank Drs Said Al-Baqlani, Suleiman Al-Busaidy, Faisal Alhamadani, Riyadh Saif-Ali Al-Hammadi, Saeed Al-Shaiba-ni, Rajae El-Aloud, Aktham Haddadin, Aisha Jumaan, Hoda Mansour, Magda Rakha, Muhammed Salman, and God-win Wilson for their mentoring support during the programme. The authors are grateful to Drs Michael Noble (Uni-versity of British Colombia), Rebecca Katz (George Washington University), Sheny Maria Morales Betouille (US CDC), Jennifer Gaudioso and LouAnn Barnett (Sandia National Laboratories) and Mr Peter Kyriacopoulos (Asso-ciation of Public Health Laboratories) for their subject matter contribution to the programme. The authors thank Jen Hubber, Priyanka Gautom and Anne Fox for assistance in manuscript preparation. Funding: The development and imple-mentation of this programme in 2013–2014 was supported by grants from the United States of America Department of State Bioengagement Program.Competing interests: None declared.

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Table 1 Participant feedback

Programme evaluation question Participant comments

What was your favourite part/aspect of the programme?

I enjoyed and benefited from the programme, all the topics were important and added to my information especially leadership and management.Although the programme was interesting and valuable in its online courses and it may save money or solve technical issues, the 2 face-to-face meetings, the kickoff and final meetings, were the preferred parts for me; in the end nothing is more valuable and informative like the face-to-face meetings .Using short videos of leaders from different institutions all over the world, sharing their points of view and experience was a great idea of the programme providers.

Have you become more interested in a particular area of laboratory management or leadership as a result of taking this programme? If so what area?

Communication skills, planning, and importance of data analysis. Systems thinking.The use of tools for improving team management.I’ve become more sensitive to Biosafety and Biosecurity issues and the regulatory aspects of laboratory management .All the contents and courses were informative but if I have to put something first then I will choose laboratory quality management system, a very critical subject; we have real problems in organizing our laboratory work. As I said in one of the discussion boards, I believe that the implementation of a quality management system is a vital part of system thinking in laboratory work.

What was the most challenging aspect of completing the Capstone assignments and why were they challenging?

Selecting the appropriate time for each steps of my work plan because it depend on my efforts also willingness of my stakeholders.Unexpected events that are outside our control, related to the general unstable condition in the country.The time for completing the project. because we all busy in many task in our job and also in continuity of online study .One of the challenges are needing approval of some implementation steps and I depending upon the prediction of the time that required for the implementation of these items in work plan. For example I need formal approval to get funds during the implementation course and this may need time.Preparing staff for change.

Were there any resources missing, that if you had them, would have helped you complete this assignment better?

More authority to implement changes.Financial resources.Time to connect with other infectious disease consultants to know from them their challenges and their concern.Stakeholders understanding of the importance of the project.

What was the most important thing(s) you learned from the Capstone project? What did you find to be of most value?

How I can organize my work and manage my time.Learning project management tools to foresee the challenges to be overcome, have a plan with detailed steps; also to have all the mitigation steps before hand and to write it down.The most valuable is to get a complete plan with all of the difficulties and how to go about it.Assigning responsibilities to my colleagues (staff of the unit). Reviewed relevant literature with practical approach to prepare meaningful project. How to develop work plan and this I shall use it in future projects. The most valuable is the part for potential challenges and mitigation plan.To act in a timely manner, to assign my priorities.Do not give up when challenges occur but always think of new ways to overcome obstacles.How to write a project implementation report.How to finish each task in its time, work in a team, cooperation with each other, and to be more creative.To compare and self-evaluate the progress during the period of implementation with organized and targeted thoughts.The most important thing I learned is the fact of being on track for information and using practical tools to ask the right questions, bring the right answers, and be structured in order to set a plan.That nothing is impossible, just you need to work hard at it.I learned presentation skills.

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A well-functioning national health information system (HIS) is a prereq-uisite for the provision of reliable and timely health-related information. This information is essential for: 1) policy development and evidence-informed decision-making; 2) proper health management and rational resource al-location; and 3) monitoring and evalua-tion of health systems and other related social services performance. National HIS draw upon multiple data sources, including civil registration and vital statistics systems, census, population-based surveys, routinely generated data from health facilities and administrative information systems. These are support-ed by governance structures, human and financial resources infrastructure and information, communications technology, quality assurance proce-dures, data management and standards, and clear plans for dissemination, use of the information and evidence generated from the system.

Learning from the experience of the Millennium Development Goals (MDGs), generation, availability and accessibility of timely and quality in-formation for key health indicators is essential for monitoring the progress to-wards achieving the targets of the health-related Sustainable Development Goals (SDGs). Despite the progress made by many countries in monitoring health during the MDG era, the lack of reli-able, timely and comparable informa-tion in low- and most middle-income countries remains an issue (1) and often hampers tracking and evaluation of progress. As a result, there has been

reliance on estimates and modelling to substitute for unavailable key indica-tors. This process surely comes with important limitations, including obser-vations from national authorities that argue the estimates do not always reflect the reality in countries. This situation calls for effective and sustained action to strengthen national health information systems, as well as reinforce the capacity of countries in generating, compiling, analyzing, disseminating and report-ing reliable data for the monitoring of health situations in countries.

For the specific case of the SDGs, several SDG3 targets focus on different measures of mortality. These range from maternal mortality, nenonatal mortality, preventable mortality from noncom-municable diseases (NCDs), and mor-tality from environmental hazards, to road traffic accidents and other forms of violence (2,3). Consequently, strength-ening national civil registration and vital statistics is imperative if countries are to have adequate data systems. This is especially important when 53% (4) of all deaths globally are not appropriately registered and only one in five deaths in the Region (5) is medically certified and coded using the International Clas-sification of Diseases (ICD), which also suffers from non-ignorable proportions of ill-defined causes (6,7). As a result, the reporting of cause-specific mortal-ity in the SDGs’ monitoring and ac-countability framework will face notable constraints if further improvements are not achieved. This area has seen very little progress over the past 25 years; in 2014, only 50% of Member States,

globally, reported cause-of-death data to WHO, compared to 45% in 1990 (8). Regionally, only 11 countries regu-larly reported to WHO cause-specific mortality data during 2008–2012 (9).

Strengthening HIS in countries of the Eastern Mediterranean Region (EMR) has been given a special priority in WHO’s work in the Region during the past five years. Extensive work was done by the WHO Secretariat and a series of regional meetings – engaging multisectoral representatives of Mem-ber States, relevant United Nations (UN) agencies and regional organiza-tions – were organized. The aim was to review the regional situation, identify constraints and collectively develop and implement strategic directions to ad-dress these, and support countries in reinforcing informed decision-making and strengthening their capacity to monitor national health development. The outcome of this work was regularly presented, discussed and endorsed at the highest level by Ministers of Health and other health policy-makers dur-ing the annual sessions of the WHO Regional Committee for the Eastern Mediterranean and other high-level meetings. Two Regional Committee resolutions were passed, which now represent a roadmap for countries and serve as the basis of WHO’s work (10). The objective of this paper is to review the current status, actions taken and present the priorities and strategic di-rections for both countries, WHO and other partners in this area of work.

1WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt

Report

Strengthening national health information systems: challenges and responseA. Alwan 1, M. Ali 1, E. Aly 1, A. Badr 1, H. Doctor 1, A. Mandil 1, A. Rashidian 1 and O. Shideed 1

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The current status

Throughout WHO’s work with EMR Member States, a number of common gaps have been identified, which hin-der development and strengthening of national HIS. There is often a lack of clarity on the essential health indicators that should be monitored as core in all countries. In many countries, political commitment and priority given to HIS is inadequate due to fragmentation of existing systems coupled with low ca-pacity to collect, verify and disseminate data and information.

In 2012, efforts to strengthen health systems in the Region were initiated with detailed situation analysis of the status of different components of the health systems in Member States (11). For practical reasons, Member States were categorized into three groups based on population health outcomes, health system performance and health expenditure1. A more in-depth analysis of the situation of national HIS across the three groups of countries was re-ported during the 61st Session of the WHO Regional Committee for the Eastern Mediterranean in 2014 (9). The conclusion drawn was that although countries across the three groups are at different stages of development, avail-ability of skilled human capacity and financial resources, there are still major gaps that are shared across the three groups of countries.

All Group 1 countries have national HIS centres or units with dedicated staff

1 Group 1) Six countries where socioeconomic development has progressed considerably over the last four decades, supported by high income; Group 2) Ten countries, largely middle-income, which have developed an extensive public health service delivery infrastructure but face resource constraints; Group 3) Six countries facing major constraints in improving population health outcomes as a result of lack of resources for health, political instability, conflicts and other complex development challenges.

as well as national plans. However, some plans are of limited scope in the areas of data collection, data analysis and ca-pacity strengthening. In all countries, national HIS are computerized, with varying degrees of functionality and integration. With regards to basic data quality assessments and feedback, they are performed in all countries, although the assessment is not based on standard-ized tools and processes. All countries regularly publish annual health statistics reports in various formats (i.e. print, digital and World Wide Web), noting that dissemination through the World Wide Web has improved substantially in recent years.

A set of defined national indicators exists in most Group 1 countries with varying degrees of quality, complete-ness and frequency of reporting. All, except one country, collect cause-spe-cific mortality data using ICD, but the quality of the collected data is an issue in all except one country. At the time of the review in 2014, the percentage of re-porting of indicators ranged from 25% to 80%. Specifically, the reporting of: i) health determinants and risks indica-tors ranged from 25% to 90%; ii) health status indicators in all countries except one; and iii) health system response in-dicators ranged from 10% to 80%. A key challenge is regular updating of popula-tion data by age, sex, and nationality due to the high rate of in- and out-migration in these countries.

All Group 2 countries, except one, have national (and subnational) HIS centres with predominately informa-tion technology (IT) staff, as well as a national plan in the majority of the countries. Basic data quality assess-ments and feedback are limited; while all countries publish annual health sta-tistics reports, only two disseminate these reports through the World Wide Web.

A set of core national and pro-gramme-specific indicators are defined in most Group 2 countries, and range from 52 to 152 indicators. Only one

country reports complete cause-specific mortality data using ICD on a regular basis. Birth and death data are gener-ally incomplete, as well as data on hu-man resources for health. At the time of the review in 2014, the reporting of: i) health determinants and risks indica-tors ranged from 50% to 60%; ii) health status indicators at 70%; and iii) health system performance indicators at 50%.

All Group 3 countries, except two, have national HIS centres or units that lack capacity in most countries, espe-cially those at the periphery, with only a few having a national plan, which is often outdated or incomplete. Data quality assurance and analysis through systematic methods are lacking. While all countries, except one, publish annual health statistics reports, there is a 2 to 3 year time lag. Across all countries, dis-semination of health statistics through the web is either unavailable or inac-cessible. Population-based and facility-based surveys are not conducted on a regular basis.

Most Group 3 countries lack a sys-tem of routine reporting, especially on cause-specific mortality data, with ICD coding not systematically used in all countries. At the time of the review in 2014, the reporting of: i) health deter-minants and risks indicators was at 50%; ii) health status indicators were few and largely based on global estimates; and iii) health system performance indica-tors were less than 50% in the majority of countries.

Other constraints include:

1. Weak coordination between national stakeholders and fragmentation of health information and civil registra-tion and vital statistics systems, both within and across ministries. This also includes:

– Limited access to routinely gener-ated health care service data from the private sector, and often ser-vices by public health systems not under the ministry of health (e.g.

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insurance organizations, armed forces)

– Lack of national comprehensive plans for health information sys-tems including national population surveys and irregular conduct of such surveys

– Limited governance or legal over-sight from ministries of health and national statistics offices in obtain-ing the required data and ensuring their availability as part of use.

2. Weak and often incomplete report-ing of deaths, cause-specific mortality data, the use of ICD and mortality statistics.

– Out of 131 Member States, glob-ally, with vital registration systems that provided summary data on cause-of-death statistics to WHO, only 60 countries had data that met certain criteria of completeness, ac-curacy, regular reporting, and disag-gregated by sex and age (12).

– Out of the 22 countries of the Re-gion, seven have never reported to WHO causes of death using ICD. Eleven countries (50%) have major gaps in mortality data reporting and only four countries have continu-ously reported annual mortality data (13).

3. Weak reporting on key morbidity indicators: population-based cancer registries and integrated disease sur-veillances are weak or non-existent in most countries.

– In the 2015 Global Survey on as-sessing national capacity for the prevention and control of NCDs conducted by WHO, less than 60% (14) of countries are reporting data on cancer incidence and type based on a population based cancer reg-istry.

4. Ineffective leveraging of opportuni-ties provided by information com-munication and technology (ICT) in data collection, analysis and dis-semination.

5. Inadequacy of quality assurance pro-cedures and lack of use or shared un-derstanding of data collection and use standards and procedures.

6. Routinely collected data (e.g. health service data) often are not linked with established quality assurance proce-dures.

7. Shortage of skilled human resources in epidemiology, statistics, IT and disease and risk factors surveillance.

– Preliminary results from assess-ments of essential public health functions in countries of the Re-gion clearly demonstrate shortage of skilled human resource capacity in related health information disci-plines. In many cases where capac-ity exists in the countries, retention and adequate distribution poses a challenge.

What is an effective health information system?

Health information systems include all activities and resources related to public health monitoring and reporting. This includes collecting data from the health sector and other relevant sectors, ana-lysing the data and ensuring their overall quality, relevance and timeliness, and converting data into information for health-related decision-making (15). Health information systems provide the underpinnings for decision-making and have five key functions: data generation, compilation, analysis and synthesis, communication of information, and use (Figure 1).

The Health Metrics Network de-fines a national HIS as being “made up of all the data and records about the population’s health. The sources of data include civil and vital registration (recording births, deaths and causes of death), censuses and surveys, individual medical records, service records and

financial and resource tracking informa-tion” (16) .

For policy-makers who recognize the major gaps that exist in their national HIS and the constraints encountered in addressing them, one practical ques-tion is to determine the essential health indicators that they need to monitor as part of their commitment to strengthen their health system and achieve univer-sal health coverage. Because countries will vary in terms of socioeconomic development and health achievements, it is important to identify what is core for all countries irrespective of income and public health capacity and what can be added as an expanded list to cater for national priorities and programme-specific needs.

There is also agreement that good quality data on a small number of key in-dicators is more informative for policy, planning and prioritization than a larger number of indicators generated from unreliable data. With this understand-ing, the WHO Regional Office for the Eastern Mediterranean facilitated and led extensive discussions with Member States and partners through a series of technical meetings and expert con-sultations conducted between 2012 and 2014. The focus of the discussion was to have an in-depth assessment of the current status of health information systems including civil registration and vital statistics and identify the type of indicators that are considered essential in monitoring health trends and health development.

Two strategic initiatives to strengthen health information systems

It was clear from the in-depth as-sessment conducted in 2012 on the regional health challenges that reinforc-ing health information systems is one of the key priorities for WHO’s work with Member States . In this respect,

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two main strategic directions were adopted: a) reaching consensus on a practical framework for national HIS and establishing a core set of indicators that can be feasibly implemented in all countries; and b) strengthening civil registration and vital statistics as one of the most critical elements of HIS.

Both strategic directions require the commitment and active engagement of other government sectors outside health.

Health Information Systems framework and regional core indicators There have been several global frame-works proposed for HIS (17–19). The challenge policy-makers face is to adopt a framework that is practical, easy to understand, feasible to implement and covers the key areas necessary for health policy development and monitoring. Both WHO and Member States of the Region agreed that the three broad areas requiring action and monitoring are the essential determinants of health, health status, and health system capac-ity and response. This consequently led to consensus on the key components of a national HIS and identification

of what needs to be monitored under each component (Figure 2). The three areas are: i) monitoring health risks and determinants; ii) assessing health status including morbidity and cause-specific mortality; and iii) evaluating health system performance.

To realize the Framework and en-sure that national HIS are capable of effectively tracking health issues, it was agreed that a minimum dataset of core indicators should be prioritized and collected. Through a series of meetings, spanning 2013 and 2014, work contin-ued to develop a list of core indicators (Figure 3) with a concise metadata reg-istry. Every effort was made to ensure that the included indicators are valid, specific, relevant, feasible and affordable to generate. In consultation with Mem-ber States, stakeholders and experts, a total number of 68 core indicators were agreed, with an expanded (as rel-evant) list of 115 additional indicators for countries that need to have a wider coverage according to their capacity and needs. In this respect, since most countries are currently unable to report reliably on all the core indicators, it will be important for them to prioritize ad-dressing the gaps before expanding.

An essential part of the initiative was the active engagement of stakeholders from ministries of health and interior, as well as central bureaus of statistics or national statistics offices; UN agencies; and international and regional experts.

The aim of the regional context-specific concise metadata registry (20), which draws upon the WHO global metadata registry, is to facilitate stand-ardized data collection, analysis and reporting. A number of attributes are described for each indicator, including: the indicator name and abbreviated name, domain/subdomain, related/associated term(s), definition, meas-urement and estimation methods, pri-mary/preferred and alternate/other possible data source(s), disaggregation and measurement frequency, numera-tor and denominator (see annex 1 for an example) (9,21).

Since its endorsement during the 61st Session of the WHO Regional Committee for the Eastern Mediter-ranean in 2014, WHO reports annually on the core indicators and verifies data with Member States (22). This has also served as the basis for the data that is in-cluded in the brief health system profiles that are updated annually and provide

Figure 1. National health information systems

Key sources of data

Data generation

Data compilation

Data analysis and synthesis

Information communication

Use for policy development, monitoring and evaluation

Civil and vital registration

Census and surveys

Individual medical records

Service and facility records

Financial and resource tracking information

Key functions of a national health information system

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a snapshot covering key health system indicators, achievements, strengths, weaknesses and priorities for action. The health system profiles aim to help policy-makers focus on the assets and challenges within their countries.

The Regional Office has embarked on a process to assess countries’ capac-ity in reporting on the core indicators, through a rapid assessment. The assess-ment of country capacity to regularly report on the core indicators is a basic step to support countries to plan for their HIS strategy and monitor their progress towards achievement of SDGs targets. The first phase of the initiative has entailed the development of an as-sessment tool on the capacity to report on the core indicators, covering key domains of: existing data sources, fre-quency of data collection, data analysis, existing resources and use of appropri-ate standards for data collection, pro-cessing, and analysis. Member States undertook the rapid assessment, which was completed by most countries in August 2016 through a web-based questionnaire.

The initial results of 19 countries that participated in the survey reveal

that although there is an improvement in reporting on the core indicators since their endorsement in 2014, none of the countries in the Region are able to report on all 68 core indicators in a timely manner. In 2016, reporting on the core indicators ranged from a minimum of 38 indicators and a maxi-mum of 58 indicators (Figure 4). The results were discussed during a regional meeting of country delegations during August 2016. Discussions included key challenges and approaches to ensure that countries have functional health in-formation systems, are able to conduct population-based surveys, improve reporting of the core indicators, and report on the SDG indicators that are not part of the core health indicators.

Improving civil registration and vital statistics systems As mentioned before, assessing health status is one of the three basic compo-nents of HIS. It covers reporting and monitoring of cause specific mortality, which represents a major gap in HIS globally and in the EMR particularly. Addressing this gap requires strength-ening of civil registration and vital statis-tics (CRVS).

Civil registration refers to “the con-tinuous, permanent, compulsory, and universal recording of the occurrence and characteristics of vital events (live births, deaths, fetal deaths, marriages, and divorces) and other civil status events pertaining to the population as provided by decree, law or regulation, in accordance with the legal requirements in each country” (23,24).

A special priority has been given to CRVS by WHO as part of the regional initiative to strengthen national HIS in Member States. A starting point was to assess the current status in countries of the region. Rapid assessments of CRVS were carried out in 21 countries, using a standard assessment tool (25) in all countries from November 2012 to Jan-uary 2013, through multi-stakeholder meetings. This was followed by compre-hensive assessments (26) conducted in 21 countries from 2013 to 2016. Results of the assessments revealed that only 6 countries (29%) have satisfactory CRVS systems that produce data of suf-ficient quality to adequately cover the needs for policy decision-making (Fig-ure 2). However, the systems in these countries cover only 5.3% of the EMR population. Eight countries (almost

Figure 2. Framework for health information systems – core indicators

Key components of a national health information system

Health status

A list of core indicatiors on:

– life expectancy and mortality

– morbidity

A list of core indicatiors on:

– demographic and socioeconomic detereminants

– risk factors

A list of core indicatiors on: – health financing – health workforce – health information system – medicines and medical devices – service delivery – service coverage

Health determinants and risks

Health system response

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40%) have either weak or dysfunctional CRVS systems (27). Additionally, the assessments revealed a major gap in birth and death registration, where more than six million (40%) births and more than three million (67%) deaths are unregistered (Figure 5). Further-more, only 19% of deaths are registered and medically certified with adequate cause-of-death registration (Figure 6). Analysis of death registration figures by country indicated that almost half of the countries in the region (12 countries) attain registration figures equal to or greater than 80% while only 6 countries have registration figures lower than the regional average of 33%. These six coun-tries are now the focus of WHO’s efforts to strengthen this area of work.

A regional strategy for the im-provement of civil registration and

vital statistics systems was developed by WHO, through intensive consultations with Member States and stakeholders. The strategy endorsed by the WHO Regional Committee in 2013, includes seven strategic domains (6):

1. Ensure a sound legal and regulatory framework for civil registration and vital statistics systems.

2. Strengthen registration infrastruc-ture, resources and capacities.

3. Remove barriers at all levels to reg-istration and the issuance of related legal documentation.

4. Improve mortality certification and coding practices.

5. Improve production, use and dissem-ination of vital statistics.

6. Improve intersectoral coordination and alignment among civil registra-tion and vital statistics stakeholders.

7. Maintain and strengthen the existing regional and global partnerships in support of country strategies.The strategy is designed to provide

Member States with a list of interven-tions to implement, based on the level of development of their civil registration and vital statistics systems, country con-texts, resources and capacities.

Based on the results of the rapid and comprehensive assessments conducted in countries over the past few years, WHO recently provided each Member State with a specific road map with a list of prioritized actions. Work has fo-cused on providing technical expertise to help the relevant national authorities

Figure 4. Number of core indicators available, per country

30 34 38 42 46 50 54 58 62 66

Afghanistan

Bahrain

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Egypt

Iran (Islamic Republic of)

Iraq

Jordan

Kuwait

Lebanon

Libya

Morocco

Oman

Pakistan

Palestine

Qatar

Saudi Arabia

Somalia

Sudan

Syrian Arab Republic

Tunisia

United Arab Emirates

Yemen

Number of core indicators reported in 2016Number of core indicators reported in 2014

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to take appropriate action and address the identified gaps.

The country-specific recommen-dations focus on a number of shared issues: 1) establishing national commit-tees to oversee CRVS implementation; 2) establishing and updating electronic civil registration systems to follow inter-national standards for recording births, deaths and causes of deaths; 3) develop-ing a birth/death notification process to capture vital events that occur in com-munities; 4) enforcing decrees that for-bid burials without death certificates; 5) expanding registration infrastructure by providing required resources; 6) capac-ity building in ICD-10 for physicians and training of medical students; and 7) capacity building in analysis and quality checks of vital statistics data.

The way forward and policy implications

The work conducted over the last five years has provided comprehensive information and a clear picture of the situation in each country with regards to their national HIS including civil regis-tration and vital statistics. The joint work with countries and other stakeholders has also resulted in a clear vision and an evidence-based roadmap for both the Region and individual countries.

The HIS framework adopted in the Region has been appreciated by policy-makers as a well-defined, practical and focused approach, yet covering the es-sential data necessary for policy-making and monitoring of national health de-velopment. As mentioned before, a core set of 68 indicators under the three key components of the framework provides a comprehensive assessment of health situation in countries and the capac-ity and response of the health system. Some countries may argue for a higher number of indicators covering addi-tional aspects and will use the expanded list. However, there is consensus among countries that the first priority is to

address the gaps that currently exist in reporting on the core indicators. In this respect, it is encouraging to observe a significant improvement in the report-ing of the core indicators since their endorsement in 2014.

The extensive work with Member States and other stakeholders has also laid the foundation for improving the completeness and accuracy of registra-tion of birth and causes of death. Coun-tries now have sound and clear guidance represented by the regional strategy for the improvement of civil registration and vital statistics 2014–2019. More specifically, using the rapid and com-prehensive assessments, each country has been provided with an inclusive list of key gaps and a set of strategic actions to address them.

Several factors have contributed to the achievements made over the last five years. The wisdom of Member States in endorsing the five key priorities has resulted in a practical agenda for the joint work between WHO and Mem-ber States, which included a focus on strengthening HIS as an integral part of the strategic directions set for each of the five regional priorities. Within

WHO, the leadership and commitment of all departments and the active en-gagement across the three levels of the Organization was a prerequisite for suc-cessful initiatives. An effective approach to improve HIS and civil registration and vital statistics will not be possible without the ownership and joint work with other key sectors within countries and other stakeholders and UN agen-cies at the country and regional levels. The participation of representatives of ministries of interior and national statis-tics offices has been key in designing the framework and development of rational and feasible multisectoral strategic ac-tions.

Further and sustained progress is dependent on the commitment and leadership of the relevant sectors at the national level. Monitoring progress in implementing the framework and the recommendations for improving civil registration and vital statistics will mo-tivate national action and is essential in guiding effective support from WHO and its partners.

Functional HIS will require sus-tained investments in strengthening national capacities in epidemiology,

Figure 5 CRVS functionality (number of countries) - Results of rapid self-assessment in countries of the Region (2012–2013)

Figure 6 Coverage of death registration in the Region (2012–2013)

67%

14%

19%

Registered and medically certified

Registered but not medically certified

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Functional but inadequate

Weak or dysfunctional

7

8

6

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statistics, data collection, compilation, quality assessment, validation and ad-justment, as well as analysis and review. Training is therefore a priority in all countries, irrespective of their health-care status or socioeconomic develop-ment.

Finally, implementing the health information framework, the regional strategy for the improvement of civil registration and vital statistics system, and the WHO recommendations to countries in the Region –particularly low- and middle-income countries – will require adequate resources, both

technical and financial. Global and regional support will be needed. Coun-tries should be able to receive support from existing global initiatives (28,29) and efforts that provide a platform for collective and aligned action and the monitoring of progress towards the SDGs.

Annex 1 Sample from the Eastern Mediterranean Region core indicators registry

11. Exclusive breastfeeding rate 0-5 months of age

Abbreviated name Exclusive breastfeeding rate

Exclusive breastfeeding 0–5 months of age

Indicator name Health determinants and risk/risk factors

Domain/subdomain Children ever breastfed – Continued breastfeeding at 1 year – Continued breastfeeding at 2 years – Duration of breastfeeding – Early initiation of breastfeeding – Exclusive breastfeeding under 6 months – Nutrition

Related/Associated terms Proportion of infants 0–5 months of age (<6 months) who are fed exclusively with breast milk

Definition Percentage of infants 0–5 months of age who are fed exclusively with breast milk = (Infants 0–5 months of age who received only breast milk during the previous day/Infants 0–5 months of age) x 100. Current status data are used. Vitamins and mineral drops or medicines are not counted.

Numerator Number of infants 0–5 months of age who are exclusively breastfed

Denominator Total number of infants 0–5 months of age surveyed

Method of estimation WHO maintains the WHO Global Data Bank on Infant and Young Child Feeding, which pools information mainly from national and regional surveys, and studies dealing specifically with the prevalence and duration of breastfeeding and complementary feeding. The process includes data checking and validation

Disaggregation Administrative regions, health regions, location (urban/rural), gender

Primary/preferred data sources

Household surveys, specific population surveys, surveillance systems

Alternative/other possible data sources

National health surveys

Measurement frequency Every 3–5 years

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WHO events addressing public health priorities

Introduction

Participants in a recently held regional consultation on development of the bridge programme for capacity-building in the Eastern Mediterranean Region (EMR) (1) agreed that Member States should advocate for establishing, strengthen-ing and expanding sustained and effective refresher course(s) for general practitioners (GPs) working in public/ private sectors to develop further their knowledge and skills to improve the quality of healthcare provided at primary health care level.

In this regard, through a joint collaboration with the Department of Family Medicine at the American University of Beirut Medical Center (AUBMC), WHO has developed a short online course to orient GPs on principles and elements of primary care services, including clinical management of common diseases. The objectives of the joint collabora-tion were discussed in two-day regional consultations with representatives from health ministries, higher education min-istries and GP syndicates/associations from Egypt, Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Pakistan, Saudi Arabia, Sudan and Tunisia.

Objectives

• To share regional situation of family practice programmes: challenges and priorities.

• To present the contents and curriculum of the proposed online training course for GPs to the key focal points/institutions responsible for continuing medical education programmes in selected EMR countries.

• To seek perceptions of key stakeholders who may intend to adapt/adopt the bridging programme in their respective countries.

• To agree on practical steps for rolling out the bridging pro-gramme, building local capacities and its institutionalization in countries of the Region.

• To build consensus on scaling up production of family medicine specialists and enhancing system capacity to at-tract family physicians in the Region.

Although physicians often work for many years serving the local community/patients who are happy with the health-care provided, they may not have had access to investment in their professional education or clinical services. These physi-cians may therefore need significant knowledge updating, and also a much broader awareness of how to be proactive (for example, for prevention and management of noncom-municable diseases) rather than giving reactive care. Another issue to address is modern orientation to appropriate primary care: many GPs received their training in medical schools, which is taught in hospital settings, and recommend tests and drugs that may not be relevant or useful in first-contact care. Finally, many physicians have had a partial case mix (only adults, children or women, etc.) and in order to give good general medical care in a primary care team they may need to revise some areas of clinical practice.

However, up-skilling GPs will not work unless all parts of the health care system understand why these broad, in-tegrative, person-centred skills are needed. A clear timeline, resource plan and support for ongoing practice and skill retention are required. This investment will only be cost-effective if other parts of the system – financing models, hospital sector, other primary health care staff and patients – use the services appropriately. Existing and upcoming family medicine specialists need a clear role and interface with their GP colleagues who are learning new skills – perhaps mutual mentorship, supervision and even referrals. Both groups will need to develop as team leaders, data analysts, service devel-opers and evidence-based practitioners. They will need to understand the application of culturally-sensitive values that work best with their individual patients and communities, to analyse and address health needs, empower and support, and manage risks and resources.

Dr Ala Alwan, WHO Regional Director for the Eastern Mediterranean, highlighted in his opening address that the shortage of family physicians is felt worldwide. However, the situation in the WHO EMR is acute and requires ur-gent action. Although Member States should do their best to strengthen family medicine departments in academic institutions, the huge shortage of family physicians will not

Developing capacity-building of general practitioners in the Eastern Mediterranean Region1

1 This report is extracted from the Summary report on the Regional consultation on development of the bridge programme for capacity-building of general practitioners in the Eastern Mediterranean Region, Cairo, Egypt, 10–May 2016 (http://apps.who.int/iris/handle/246160/10665)

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be overcome solely by the establishment of more academic departments. Other factors, including issues related to service delivery, must also be addressed based on local capacities and needs.

The Regional Director brought attention to the fact that that the current annual output of trained family physicians in the Region is around 681, against identified needs of almost 21 000 family physicians (2). According to a situation analysis carried out in late 2014, in collaboration with the World Organization of Family Doctors (WONCA) and Aga Khan University in Karachi, Pakistan, only 20% of all medi-cal schools in the Region have functional family medicine departments (2).

In this regard, the short online course developed by WHO and AUBMC includes training module that blend theoretical knowledge and practical skills based on global best practices. It has an online component along with elements of face-to-face training in which GPs can readily participate. The

training curriculum covers the main competencies that a GP/family physician has to master including: primary care man-agement, person-centred care, specific problem-solving skills, comprehensive approach and community orientation.

The training course is to be delivered in a blended format which covers 48 topics, including the management of common medical problems in primary care and family medicine core concepts. It runs over 24 weeks and is divided into four main blocks, starting with an orientation session and ending with final examinations. Each block spans a 5-week period, whereby the first 4 weeks are delivered online and the fifth week includes a 6-hour face-to-face session or live review.

In conclusion, the consultation recommended a set of ac-tions to enhance the bridge programme for capacity-building of general practitioners (Box 1), as well as actions for countries to enhance health system capacity to implement family prac-tice (Box 2).

Box 1 Actions to enhance the bridge programme for capacity-building of general practitioners

• Committees to be established at the country level to review the training course contents and oversee adaptation/revi-sion of curriculum and implementation of the programme, based on local needs and capacities.

• AUB and WHO to work on programme evaluation, to identify measurable outcome indicators and incorporate an evaluation kit (pre- and post-test) into the course curriculum.

• Country training activities to be mentored/coached by the national trainers.• AUB to elaborate on course methodology and develop mentorship/trainers’ guide/manual to facilitate organizing

the course at country level.• Countries to consider incentives for candidates entering the family medicine specialty or enrolling in the bridge pro-

gramme, such as career path incentives or entering the postgraduate course on family medicine in local universities/fellowships with the 6-month online course as credit.

• WHO to work on advocacy, networking and marketing of the bridge programme.• Online course to be usability tested in Lebanon in a small cohort and results shared with countries of the Region. • WHO to work with AUB to ensure the online course is user-friendly and easy to operate. An information technology

specialist from each country may attend the last day of the training of trainers to be back-up support for trainers at the country level.

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Box 2 Actions for countries to enhance health system capacity to implement family practice

• Linkage of the family practice approach with national health policies, Sustainable Development Goals and other development plans.

• Allocation of funds to enhance the family practice programme at national level.• Update the essential package of health services based on community needs and ensure its implementation at all pri-

mary health care facilities on gradual basis (based on countries’ capacities and availability of health workforce). • Review laws/regulations and standards of service delivery based on family practice approach. • Strengthen partnerships (with other service providers, private sector, nongovernmental organizations) through con-

tracting out of services, covering family practice by insurance organizations, etc.• Establish/strengthen family medicine departments; capacity of intake of residency programmes to be increased.• Organize transitional period training activities for countries to move from GPs to family physicians.• Strengthen family medicine departments and incentives to ensure a certain percentage of medical doctors enter a

family practitioner residency.• Involve/train other health workforce cadres (paramedics, nurses, midwifes) on family practice approach.• Medical and nursing school curriculum to be amended to be more community-oriented, problem-based and in line

with family practice approach in order that undergraduate students become more familiar with the concept of primary care and family medicine after graduation.

• Incorporate family medicine in medical, nursing and other health professional education and curriculum (under-graduate courses) along with appropriate clinical training in primary care settings.

• Sustainable funding for expansion of the family practice programme.• Strategic purchasing, costing of essential package of health services and capacity for contracting out.• Collaborate with health insurance organizations for family practice implementation.• Introduce appropriate incentives for family practice teams to enable them to perform as expected. • Measure service delivery performance and improvement.• Define catchment population per primary health care facility, identify patient rostering, family/individual folders and

registration of individuals with primary health care facilities.• Integrate noncommunicable diseases as a priority in primary health care; strengthen referral channels; improve logis-

tics; monitoring and evaluation; home health care; team work; and ensure equity in access to services for rural, urban and poor population.

• Encourage a team approach in family practice, involving multidisciplinary teams including nurses, midwives and other health professionals as needed, and ensure an enabling working environment for them to practice as a family practice team.

• Countries to be encouraged to strengthen and engage private practitioners in service delivery through family practice approach.

• Implement WHO quality standards/indicators framework.• Enforce accreditation programme.• Establish community health boards, engage in awareness building on benefits of family practice and engage in local

planning.• Strengthen staff communication skills with the community.

References1. Regional consultation on development of the bridge pro-

gramme for capacity-building of general practitioners in the Eastern Mediterranean Region. World Health Organization Regional Office for the Eastern Mediterranean, 10–11 May 2016, Cairo, Egypt.

2. Global Health Workforce Alliance / World Health Organiza-tion. The Global Health Workforce Alliance 2014 Annual Report. Geneva: World Health Organization, 2015 (http://www.who.int/workforcealliance/knowledge/resources/an-nual_report2014/en/).